NR 602 Week 8 Final Exam Outline
Seizures
Febrile seizures
Are the most common childhood seizure, affecting 2-5% of children.
Benign and self-limiting
Usually occur between 3 months and 5 yrs
Without evidence of intracranial infection or defined cause
Peak incidence at 18 months.
The incidence in boys is slightly higher than in girls.
Excludes seizures with fever in children who have had a prior afebrile seizure.
“a seizure accompanied by fever (temperature > 100.4°F or 38°C by any method)
2 classifications simple/ complex
Simple febrile seizure (SFS)- A self-limited, short (< 15 minutes), generalized,
tonic-clonic seizure that does not recur within the same illness and is not associated
with post-ictal pathology.
Complex febrile seizures (CFS)- Febrile seizures that do not meet all criteria for
SFS.
Prolonged febrile seizure (PFS) - is a complex seizure that lasts longer than 15
minutes.
Febrile status epilepticus (FSE)- a febrile seizure that continues longer than 30
minutes is classified as FSE. FSE’s accounts for 5% to 9% of all febrile seizures and
25% of all episodes of status epilepticus occurring in children.
Despite the common belief that febrile seizures occur with rise in temperature,
there is no evidence to support this.
Febrile seizures usually develop in the first 24 hours of the illness, with 21% of
children manifesting a seizure within an hour of fever onset.
The seizure itself is the first sign of febrile illness in 25% to 50% of cases.
Seizures that occur 3 or more days after the onset of fever should be considered
unlikely to be a febrile seizure.
Seizures are complex in 9% to 35% of cases.
Risk factors for developing febrile seizures are the height of the temperature and a
positive family history in first-degree relatives.
Other identified risk factors are a neonatal nursery stay of greater than 28 days,
developmental delay, and day care attendance.
Specific infectious etiologies have been associated with febrile seizures- such as
human herpes simplex virus-6 (roseola infantum) (accounting for as much as 20%
of children presenting with first febrile seizures), shigella gastroenteritis, and
influenza A.
Immunizations, such as diphtheria-tetanus-pertussis and measles-mumps-rubella,
are associated with significantly elevated risks of febrile seizures. It is unclear
whether the association of infections and immunizations are related to the height of
the fever or some other unidentified factor.
, Children with SFS tend to present to the ER for medical care after resolution of the
seizure. They may be post-ictal and appear irritable, confused, or lethargic. Gradual
return to a normal level of alertness occurs within 1 hour, and there are no focal
deficits.
When a child present medical history should include- duration of fever, potential
illness exposure, and recent antibiotic use, neurodevelopmental delay, possible
metabolic disturbance, history of prior seizures, and other potential causes of
seizures, such as trauma or accidental ingestion, should also be considered.
Diagnostic evaluation- a child with an SFS should clarify whether the child actually
had a seizure and focus on identifying the source of fever.
The 2011 AAP clinical practice guideline recommendations state, “meningitis should
be considered in the differential diagnosis in any child with fever, and a lumbar
puncture (LP) should be performed if there are any signs or symptoms of concern”.
Other evidence supports consideration of an LP in the evaluation of a younger child
(6 to 12 months), a child who is under immunized, of questionable vaccination
status, or on prior antibiotics. Further investigations — such as blood studies,
imaging studies, or EEGs —are not necessary, unless there are specific indications
for concern based on the history and physical findings.
Treatment of an ongoing seizure consists of airway maintenance, oxygen,
supportive care, and anticonvulsants.
Rectal diazepam has been used at home and in the ER with dosing of 0.25 mg/kg to
0.5 mg/kg.
CFS and FSE are more frequently associated with meningitis than SFS. CNS
infections are unlikely, unless there are accompanying clinical findings, such as
decreased level of consciousness, meningeal signs, or toxic appearance. An LP is
frequently unnecessary unless the patient is under the age of 12 months (limiting
confidence in physical exam), displays signs of CNS infection, or does not return to
baseline mental status.
About one in four children with meningitis present with a seizure, and bacterial
meningitis occurs in up to 18% of children with CFS.
Imaging studies are not indicated in most well-appearing children with first CFS.
EEC may be considered in follow-up if there are recurrences without fever, evidence
of developmental delay or neurologic deficits.
One in three children with a febrile seizure will have another, and age (< 15 months)
appears to be the most consistent risk factor associated with recurrence.
If recurrence occurs, half will recur within the first year and 90% will occur within
2 years. Other associated factors include epilepsy or febrile seizures in first-degree
relatives, first CFS, and day care exposure. As the number of risk factors increase,
the recurrence risk increases; the presence of three or more risk factors is
associated with 80% to 100% recurrence. And recurrence may occur at lower peak
temperatures.
Epilepsy risk- Although children with febrile seizures are at increased risk of
developing epilepsy compared to healthy controls, most children with febrile
seizures (97%) will never develop epilepsy. Risk factors for developing epilepsy
following SFS is 1% to 2.4% (compared to 0.5% in the general population) and 4%
to 6% following CFS.
, There is no evidence to support the use of antipyretics for the prevention of
recurrent seizures, although they may be helpful in relieving the discomfort of a
febrile child.
Although studies have shown efficacy in reducing the recurrence rate of febrile
seizures by treating with continuous antiepileptic therapy, the AAP does not
recommend the use of prophylactic oral antiepileptic medication in children with
either SFS or CFS due to significant associated side effects.
Initial Evaluation and Management of a First Seizure in Children
Seizures are one of the most common neurologic disorders in children.
Approximately 120,000 children in the United States are seen annually for new-
onset seizure. 1% of children will experience an afebrile seizure by 14 years of age.
More than 50% of people with epilepsy had their first seizure during childhood or
adolescence.
The International League Against Epilepsy (ILAE) defines a seizure as a clinical
manifestation of excessive discharge in a population of hyperexcitable neurons in
the brain. The clinical manifestation consists of a sudden and transitory
phenomenon that may include altered consciousness, motor, sensory, autonomic, or
psychic events perceived either by the patient or by an observer.
Epilepsy is defined by the ILAE as a disorder of the brain characterized by an
enduring predisposition to generate seizures and by the neurobiological, cognitive,
psychological, and social consequences of this condition.
Children with epilepsy may also experience comorbid behavioral problems,
impaired neurocognitive function, issues with memory, school difficulties, negative
self-esteem, and reduced quality of life.
When presented with a paroxysmal event, the first question to be answered is
whether the event was indeed a seizure. The child’s history helps distinguish
between epileptic and non-epileptic events more than an EEC. Many children with
epilepsy have normal findings on EEC, and an abnormal EEC is not necessary to
make the diagnosis of a seizure.
The history should include details of the setting in which the event occurred, the
sequence of events leading up to and during the event, and the child’s behavior
following tire event.
No single sign is specific for a seizure. Seizures are often sudden, momentary
alterations in behavior that occur without warning and may be followed by a
prolonged post-ictal period of drowsiness, sleep, confusion, or weakness. Tongue
biting, incontinence, and postictal state, although not specific, often suggests a
seizure.
It is often helpful to obtain the description of the event directly from the observer,
asking the observer to show what happened either by acting out or videotaping the
event.
Risk factors for development of epilepsy include abnormal development, including
any developmental delays or apparent regression; focal neurologic findings; and
family history of epilepsy.
Seizures
Febrile seizures
Are the most common childhood seizure, affecting 2-5% of children.
Benign and self-limiting
Usually occur between 3 months and 5 yrs
Without evidence of intracranial infection or defined cause
Peak incidence at 18 months.
The incidence in boys is slightly higher than in girls.
Excludes seizures with fever in children who have had a prior afebrile seizure.
“a seizure accompanied by fever (temperature > 100.4°F or 38°C by any method)
2 classifications simple/ complex
Simple febrile seizure (SFS)- A self-limited, short (< 15 minutes), generalized,
tonic-clonic seizure that does not recur within the same illness and is not associated
with post-ictal pathology.
Complex febrile seizures (CFS)- Febrile seizures that do not meet all criteria for
SFS.
Prolonged febrile seizure (PFS) - is a complex seizure that lasts longer than 15
minutes.
Febrile status epilepticus (FSE)- a febrile seizure that continues longer than 30
minutes is classified as FSE. FSE’s accounts for 5% to 9% of all febrile seizures and
25% of all episodes of status epilepticus occurring in children.
Despite the common belief that febrile seizures occur with rise in temperature,
there is no evidence to support this.
Febrile seizures usually develop in the first 24 hours of the illness, with 21% of
children manifesting a seizure within an hour of fever onset.
The seizure itself is the first sign of febrile illness in 25% to 50% of cases.
Seizures that occur 3 or more days after the onset of fever should be considered
unlikely to be a febrile seizure.
Seizures are complex in 9% to 35% of cases.
Risk factors for developing febrile seizures are the height of the temperature and a
positive family history in first-degree relatives.
Other identified risk factors are a neonatal nursery stay of greater than 28 days,
developmental delay, and day care attendance.
Specific infectious etiologies have been associated with febrile seizures- such as
human herpes simplex virus-6 (roseola infantum) (accounting for as much as 20%
of children presenting with first febrile seizures), shigella gastroenteritis, and
influenza A.
Immunizations, such as diphtheria-tetanus-pertussis and measles-mumps-rubella,
are associated with significantly elevated risks of febrile seizures. It is unclear
whether the association of infections and immunizations are related to the height of
the fever or some other unidentified factor.
, Children with SFS tend to present to the ER for medical care after resolution of the
seizure. They may be post-ictal and appear irritable, confused, or lethargic. Gradual
return to a normal level of alertness occurs within 1 hour, and there are no focal
deficits.
When a child present medical history should include- duration of fever, potential
illness exposure, and recent antibiotic use, neurodevelopmental delay, possible
metabolic disturbance, history of prior seizures, and other potential causes of
seizures, such as trauma or accidental ingestion, should also be considered.
Diagnostic evaluation- a child with an SFS should clarify whether the child actually
had a seizure and focus on identifying the source of fever.
The 2011 AAP clinical practice guideline recommendations state, “meningitis should
be considered in the differential diagnosis in any child with fever, and a lumbar
puncture (LP) should be performed if there are any signs or symptoms of concern”.
Other evidence supports consideration of an LP in the evaluation of a younger child
(6 to 12 months), a child who is under immunized, of questionable vaccination
status, or on prior antibiotics. Further investigations — such as blood studies,
imaging studies, or EEGs —are not necessary, unless there are specific indications
for concern based on the history and physical findings.
Treatment of an ongoing seizure consists of airway maintenance, oxygen,
supportive care, and anticonvulsants.
Rectal diazepam has been used at home and in the ER with dosing of 0.25 mg/kg to
0.5 mg/kg.
CFS and FSE are more frequently associated with meningitis than SFS. CNS
infections are unlikely, unless there are accompanying clinical findings, such as
decreased level of consciousness, meningeal signs, or toxic appearance. An LP is
frequently unnecessary unless the patient is under the age of 12 months (limiting
confidence in physical exam), displays signs of CNS infection, or does not return to
baseline mental status.
About one in four children with meningitis present with a seizure, and bacterial
meningitis occurs in up to 18% of children with CFS.
Imaging studies are not indicated in most well-appearing children with first CFS.
EEC may be considered in follow-up if there are recurrences without fever, evidence
of developmental delay or neurologic deficits.
One in three children with a febrile seizure will have another, and age (< 15 months)
appears to be the most consistent risk factor associated with recurrence.
If recurrence occurs, half will recur within the first year and 90% will occur within
2 years. Other associated factors include epilepsy or febrile seizures in first-degree
relatives, first CFS, and day care exposure. As the number of risk factors increase,
the recurrence risk increases; the presence of three or more risk factors is
associated with 80% to 100% recurrence. And recurrence may occur at lower peak
temperatures.
Epilepsy risk- Although children with febrile seizures are at increased risk of
developing epilepsy compared to healthy controls, most children with febrile
seizures (97%) will never develop epilepsy. Risk factors for developing epilepsy
following SFS is 1% to 2.4% (compared to 0.5% in the general population) and 4%
to 6% following CFS.
, There is no evidence to support the use of antipyretics for the prevention of
recurrent seizures, although they may be helpful in relieving the discomfort of a
febrile child.
Although studies have shown efficacy in reducing the recurrence rate of febrile
seizures by treating with continuous antiepileptic therapy, the AAP does not
recommend the use of prophylactic oral antiepileptic medication in children with
either SFS or CFS due to significant associated side effects.
Initial Evaluation and Management of a First Seizure in Children
Seizures are one of the most common neurologic disorders in children.
Approximately 120,000 children in the United States are seen annually for new-
onset seizure. 1% of children will experience an afebrile seizure by 14 years of age.
More than 50% of people with epilepsy had their first seizure during childhood or
adolescence.
The International League Against Epilepsy (ILAE) defines a seizure as a clinical
manifestation of excessive discharge in a population of hyperexcitable neurons in
the brain. The clinical manifestation consists of a sudden and transitory
phenomenon that may include altered consciousness, motor, sensory, autonomic, or
psychic events perceived either by the patient or by an observer.
Epilepsy is defined by the ILAE as a disorder of the brain characterized by an
enduring predisposition to generate seizures and by the neurobiological, cognitive,
psychological, and social consequences of this condition.
Children with epilepsy may also experience comorbid behavioral problems,
impaired neurocognitive function, issues with memory, school difficulties, negative
self-esteem, and reduced quality of life.
When presented with a paroxysmal event, the first question to be answered is
whether the event was indeed a seizure. The child’s history helps distinguish
between epileptic and non-epileptic events more than an EEC. Many children with
epilepsy have normal findings on EEC, and an abnormal EEC is not necessary to
make the diagnosis of a seizure.
The history should include details of the setting in which the event occurred, the
sequence of events leading up to and during the event, and the child’s behavior
following tire event.
No single sign is specific for a seizure. Seizures are often sudden, momentary
alterations in behavior that occur without warning and may be followed by a
prolonged post-ictal period of drowsiness, sleep, confusion, or weakness. Tongue
biting, incontinence, and postictal state, although not specific, often suggests a
seizure.
It is often helpful to obtain the description of the event directly from the observer,
asking the observer to show what happened either by acting out or videotaping the
event.
Risk factors for development of epilepsy include abnormal development, including
any developmental delays or apparent regression; focal neurologic findings; and
family history of epilepsy.
