Practice parameter: evaluating a first nonfebrile seizure in children: report of the quality standards subcommittee of the American Academy of Neurology, The Child Neurology Society, and The American Epilepsy Society

Hypoparathyroidism in a Case of Transfusion Dependent Thalassemia

Repeated blood transfusions in transfusion dependent thalassemia (TDT) leads to iron overload-related endocrine complications. Hypoparathyroidism (HPT) with severe signs of hypocalcemia is a recognized complication among these patients.

A 14-year-old thalassaemic boy, on regular transfusion and on anticonvulsant therapy with a presumptive diagnosis of epilepsy for the last 1 year, was admitted with high fever and severe muscle cramps with positive Trousseau’s sign. He was diagnosed as a case of primary HPT and magnesium deficiency on the basis of low serum calcium, high phosphate, normal alkaline phosphates, very low intact parathyroid hormone (iPTH), normal serum vitamin D and very low serum magnesium level. His calcium, magnesium and phosphate level normalised following treatment with intravenous magnesium and calcium. His iPTH improved but remained at low normal. He was discharged from hospital with oral calcium, calcitriol, and magnesium supplementation. The anticonvulsant (Phenobarbitone) was successfully withdrawn gradually over the next six months without any recurrence of seizure in the subsequent 3 years of follow up.

Acquired HPT (apparently from hemosiderosis) is a common cause of hypocalcemia; and magnesium depletion further complicated the situation leading to severe hypocalcemia with recurrent episodes of convulsion. Magnesium replacement improved the parathyroid hormone (PTH) value proving its role in acquired HPT. Very high phosphate level on admission and poor PTH response with respect to the low serum calcium, indicates intrinsic parathyroid pathology. Metabolic abnormalities should always be evaluated in thalassaemic subject with seizure disorder and it appears that the initial convulsive episodes were due to hypocalcemia.

Muscle pain, cramps or convulsion may occur from HPT and simultaneous magnesium deficiency in transfusion dependent thalassaemic subjects. Metabolic correction is more important than anticonvulsant medication. Calcium and magnesium should both be assessed routinely in transfusion dependent thalassemic patients.

EEG for children with complex febrile seizures

BACKGROUND

Febrile seizures can be classified as simple or complex. Complex febrile seizures are associated with fever that lasts longer than 15 minutes, occur more than once within 24 hours, and are confined to one side of the child's body. It is common in some countries for doctors to recommend an electroencephalograph (EEG) for children with complex febrile seizures. A limited evidence base is available to support the use of EEG and its timing after complex febrile seizures among children.

OBJECTIVES

To assess the use of EEG and its timing after complex febrile seizures in children younger than five years of age.

SEARCH METHODS

For the latest update of this review, we searched the following databases on 12 March 2019: Cochrane Register of Studies (CRS Web), which includes the Cochrane Epilepsy Group Specialized Register and the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (Ovid, 1946 to 11 March 2019); and ClinicalTrials.gov. We applied no language restrictions.

SELECTION CRITERIA

All randomised controlled trials (RCTs) that examined the utility of an EEG and its timing after complex febrile seizures in children.

DATA COLLECTION AND ANALYSIS

The review authors selected and retrieved the articles and independently assessed which articles should be included. Any disagreements were resolved by discussion and by consultation with the Cochrane Epilepsy Group. We applied standard methodological procedures expected by Cochrane.

MAIN RESULTS

Of 48 potentially eligible studies, no RCTs met the inclusion criteria.

AUTHORS' CONCLUSIONS

We found no RCTs as evidence to support or refute the use of EEG and its timing after complex febrile seizures among children under the age of five. An RCT can be planned in such a way that participants are randomly assigned to the EEG group and to the non-EEG group with sufficient sample size. Since the last version of this review, we have found no new studies.

Relation between Febrile Seizure Recurrence and Hyponatremia in Children: A Single-center Trial

Background:

Febrile seizure (FS) is one of the most common types of seizure in pediatrics.

Objective:

The aim of this study was to compare serum sodium in children with simple or recurrent FS and seizure without fever.

Materials and Methods:

This was a cross-sectional prospective study conducted between September 2015 and April 2017 in patients aged between 6 months and 6 years, who were admitted to a tertiary educational medical center in the north of Iran. Patients were categorized into three groups, group A: simple FS, group B: recurrent FS, and group C: afebrile seizure. Serum sodium level was measured on admission and/or when the seizure occurred.

Results:

The study included 248 patients aged 6 months to 6 years. Their mean age was 22.38 ± 1.34 months. Hyponatremia was found in 6% of group A, 7.5% of group B, and 6% of group C. The mean sodium level in group A (134.46 ± 2.3 mEq/L) and group B (134.35 ± 2.06 mEq/L) did not disclose meaningful difference, but it was significantly lower in febrile groups than in the control group.

Conclusion:

Although the results did not show that the lower level of serum sodium increased the risk of seizure recurrence during the next 24h in febrile illness, lower serum sodium concentration was more common in FS groups.

New-onset seizure survey of epilepsy centers in the United States

OBJECTIVES

Children presenting with new-onset seizures have variable access to resources and may not receive timely and adequate treatment. Some may experience adverse consequences when not evaluated in a timely manner by appropriate medical providers. Consequences can be especially severe for children under the age of two and for children who have psychiatric, cognitive, and behavioral comorbidities. There are no published data on how children with new-onset seizure are evaluated and treated across the US. Our goal was to gain insight into how different epilepsy centers across the country evaluate and treat children with new-onset seizures.

METHODS

We conducted a survey of Epilepsy Centers in the US that are part of the Pediatric Epilepsy Research Consortium (PERC) and focused on children presenting with new-onset seizures; PERC is a group of pediatric epilepsy providers and researchers who participate in collaborative multicenter research in pediatric epilepsy with the goal of improving outcomes in children with pediatric epilepsy. The questionnaire was developed by the authors of this study. It was designed to provide a descriptive assessment of the consistency and variability in how patients with new-onset seizure are evaluated and treated at epilepsy sites across the country. The questionnaire was designed to assure all points of interest were explored. The questions were aimed at describing access to care, how care is delivered, whether centers prioritize based on clinical presentation and/or age, and availability of resources. The survey was sent to 80 epileptologists at 42 different Epilepsy Centers that are part of PERC.

RESULTS

Respondents included 29 pediatric epileptologists representing 24 unique centers. In the cases where there were multiple respondents from each center, response of the most senior epileptologist was used. It is possible that the senior epileptologist may have not known about the center as much as a junior epileptologist, but this was used to establish consistencies among centers with multiple respondents. Results showed that 30% of centers had a dedicated new-onset seizure clinic. The median time for children to be seen was two to four weeks, and 12% reported that it takes more than five weeks until the patient is seen. There was a trend toward centers with new-onset seizure clinic having less wait times. Most centers identified lack of adequate care based on insurance coverage, resources, long wait times, and long travel times.

SIGNIFICANCE

Most centers (70%) do not have a dedicated new-onset seizure clinic. Children presenting with new-onset seizures often do not receive timely and comprehensive care because of limitations in resources and lack of established standard of care. Standardizing care for patients presenting with new-onset seizures has not yet occurred in the US. Many centers do not have a screening process and employ staff other than physicians or nurses for screening and triaging patients. This study shows that having a neurologist or epileptologist in charge of triaging does not reduce wait times. This survey revealed that there is substantial variability in how these patients are evaluated. Although this study shows a trend for epilepsy centers with new-onset seizure clinic having less wait times, even when there is a new-onset seizure clinic, wait times can be greater than five weeks. Overall, however, a new-onset seizure clinic may be an effective way to improve access to timely and efficient care for these patients.

Eight-year-old Boy with New-onset Seizure

An eight-year-old boy presented to the emergency department for a first-time seizure. The patient had only signs of mild dehydration on physical exam and had an uneventful postictal recovery. First-time seizures in pediatric patients are often benign and require only an outpatient workup; some are dangerous. This case takes the reader through the differential diagnosis and systematic work-up of new-onset pediatric seizures, leading to an unanticipated diagnosis.

Is my baby normal? A review of seemingly worrisome but normal newborn signs, symptoms and behaviors

Infant patients are a unique challenge to emergency department (ED) physicians as the spectrum of normal infant signs, symptoms and behaviors are often difficult to differentiate from abnormal and potentially life-threatening conditions. In this article, we address some common chief complaints of neonates and young infants presenting to the ED, and contrast reassuring neonatal and young infant signs and symptoms against those that need further workup and intervention.

First-ever convulsive seizures in children presenting to the emergency department: risk factors for seizure recurrence and diagnosis of epilepsy

AIM

Aetiologies of first-ever convulsive seizures may be diverse, not all leading to recurrence or epilepsy diagnosis. We aimed to describe the epidemiology of first-ever convulsive seizures in children, investigating risk factors for recurrence and epilepsy diagnosis.

METHOD

This was a retrospective study of children presenting with a first-ever convulsive seizure to a tertiary-care paediatric emergency department (PED) in Italy, in a 12-month period (2011-2012).

RESULTS

One hundred and eight children (57 males, 51 females) presented to the PED for a first-ever convulsive seizure; 90.7% were 6 months to 6 years old (median age 1y 10mo, mean 2y 7mo, range 0mo-14y 4mo). Seizure duration was less than 5 minutes in 76.8%. Seizures were 'unprovoked' in 19.4% and 'provoked' in 80.6%. At 4-year follow-up, 37.9% of patients experienced recurrence and 13.6% received a diagnosis of epilepsy. Factors significantly associated with recurrence were the 'unprovoked' nature of the first seizure, multiple seizures in the first 24 hours, positive family history of febrile seizures or epilepsy, and pre-existing neurological conditions/problems. Factors significantly associated with a diagnosis of epilepsy were the 'unprovoked' nature of the first seizure, age older than 6 years, pre-existing neurological conditions/problems, and focal onset of first seizure.

INTERPRETATION

Children presenting to the PED with first-ever convulsive seizures represent a heterogeneous group. The identification of prognostic factors for recurrence and epilepsy diagnosis may help provide tailored counselling and follow-up.

WHAT THIS PAPER ADDS

Seizures were 'unprovoked' in 19.4% and 'provoked' in 80.6% of children presenting to the emergency department. At 4-year follow-up, 37.9% relapsed, and 13.6% received a diagnosis of epilepsy. 'Unprovoked' first seizure, family history of febrile seizures, and pre-existing neurological conditions were associated with recurrence. 'Unprovoked' first seizure, age younger than 6 years, and pre-existing neurological conditions were associated with epilepsy diagnosis.

Variation in Pediatric Care Between Academic and Nonacademic US Emergency Departments, 1995-2010

OBJECTIVES

The aim of this study was to describe the resource utilization for children with common pediatric conditions treated in academic and nonacademic emergency departments (EDs).

METHODS

We performed a retrospective, cross-sectional descriptive study using the National Hospital Ambulatory Medical Care Survey Data from 1995 to 2010 including children less than 18 years old with a diagnosis of asthma, bronchiolitis, croup, gastroenteritis, fever, febrile seizure, or afebrile seizure. Academic EDs (A-ED) were those with greater than 25% of patients seen by a trainee. For each condition, we reported the proportion of testing, medications, and disposition between A-ED and nonacademic EDs (NA-ED).

RESULTS

From 1995 to 2010, approximately 450,000,000 estimated pediatric visits are represented by the survey based on 122,811 actual visits. For most common conditions, testing and disposition were comparable; however, some variation was noted. Among patients with bronchiolitis, a higher proportion of patients was admitted and had radiographs in NA-EDs (18% vs 10% and 56% vs 45%, respectively). For children with croup, radiographs were performed more often at NA-EDs (27% vs 6%). Among those with febrile seizures, more lumbar punctures were performed in NA-EDs (14% vs 0%). In children with afebrile seizures, more head computed tomography scans were obtained at NA-EDs (34% vs 21%).

CONCLUSION

Among pediatric patients with croup, bronchiolitis, and febrile and afebrile seizure, higher resource utilization and admissions were observed in NA-EDs. These preliminary findings from a national survey require a more detailed investigation into the variation in care between A-ED and NA-ED settings.

Is Shunt Evaluation Useful in Children With Intraventricular Shunts With Seizures?

BACKGROUND

Seizures are a common presenting symptom to the emergency department (ED) in children with intraventricular shunts (IVS). The incidence of shunt malfunction and the yield of imaging studies in children with IVS presenting with seizures is unknown.

OBJECTIVES

We assessed the utility and diagnostic yield of evaluation for shunt malfunction in patients with IVS with seizure and identified clinical predictors for shunt malfunction in these children.

METHODS

We performed a retrospective review of children aged zero to 21 years of age with IVS who presented to the ED with seizure between 2011 and 2015. Demographic, clinical, laboratory and radiological data were collected. Shunt malfunction was diagnosed based on whether a shunt revision was performed during the hospitalization.

RESULTS

We evaluated 408 ED visits (median age: six years [IQR: 3, 11], males 61.5%) for IVS with seizures. Few visits were for first seizure (37; 9.1%) or for status epilepticus (46 visits; 11.3%). Computerized tomography head was performed in 318 patients (95.2%), of which 32 scans (10.6%) were suggestive of shunt malfunction. A shunt series was performed in 302 (90.4%) and was suggestive of shunt malfunction in eight (2.6%) patients. Shunt malfunction was diagnosed in 40 of 408 visits (9.8%). Only a history of multiple (≥3) shunt revisions was significantly associated with shunt malfunction. There was no association between number, type, or prior history of seizures and shunt malfunction.

CONCLUSION

Our study demonstrates a low yield of imaging studies for the evaluation of shunt malfunction in children with IVS with seizures, and shunt malfunction is an uncommon cause of seizures in these children.

Use of Head Computed Tomography (CT) in the Pediatric Emergency Department in Evaluation of Children With New-Onset Afebrile Seizure

OBJECTIVE

Cranial computed tomography (CT) is not recommended in the routine evaluation of children with first afebrile seizure due to its low yield. The objective was to assess the current practice in our pediatric emergency department regarding the use of head CT in children with first afebrile seizure and to identify the factors that lead to ordering a head CT.

METHODS

Medical records of patients between 1 month and 18 years old evaluated at our emergency department for presentation of first afebrile seizure between 2010 and 2014 were retrospectively reviewed. Data extracted include age, gender, seizure type, single or multiple seizures at presentation, seizure duration, predisposing conditions to seizures (ie, history of developmental delay), and whether a head CT was performed. Contingency tables with chi-square analyses were used to determine which variables were associated with increased use of head CT.

RESULTS

Of 155 patients (88M/67F) included in the study, 72 (46.5%) underwent head CT and only 3 had clinically significant findings that did not require acute management. There were no differences in CT use by age, sex, seizure type, seizure number, seizure risk factors, or findings on physical examination. Head CT was performed more frequently in cases with seizures ≥5 minutes and unknown seizure duration ( P = .04).

CONCLUSION

Despite existing evidence, the emergent head CT rate was high in our cohort. Children with seizure duration of ≥5 minutes or of unknown duration were more likely to undergo head CT in our emergency department.

Neuroimaging of Early Life Epilepsy

OBJECTIVES

We assessed the adherence to neuroimaging guidelines and the diagnostically relevant yield of neuroimaging in newly presenting early life epilepsy (ELE).

METHODS

There were 775 children with a new diagnosis of epilepsy (<3 years old at onset) who were recruited through the ELE study at 17 US pediatric epilepsy centers (2012-2015) and managed prospectively for 1 year. The data were analyzed to assess the proportion of children who underwent neuroimaging, the type of neuroimaging, and abnormalities.

RESULTS

Of 725 children (93.5%) with neuroimaging, 714 had an MRI (87% with seizure protocols) and 11 had computed tomography or ultrasound only. Etiologically relevant abnormalities were present in 290 individuals (40%) and included: an acquired injury in 97 (13.4%), malformations of cortical development in 56 (7.7%), and other diffuse disorders of brain development in 51 (7.0%). Neuroimaging was abnormal in 160 of 262 (61%) children with abnormal development at diagnosis versus 113 of 463 (24%) children with typical development. Neuroimaging abnormalities were most common in association with focal seizure semiology (40%), spasms (47%), or unclear semiology (42%). In children without spasms or focal semiology with typical development, 29 of 185 (16%) had imaging abnormalities. Pathogenic genetic variants were identified in 53 of 121 (44%) children with abnormal neuroimaging in whom genetic testing was performed.

CONCLUSIONS

Structural abnormalities occur commonly in ELE, and adherence to neuroimaging guidelines is high at US pediatric epilepsy centers. These data support the universal adoption of imaging guidelines because the yield is substantially high, even in the lowest risk group.

Adolescent Seizure in the Emergency Department Due to Concomitant Brugada Syndrome

Brugada syndrome is an increasingly discussed entity in the emergency medicine and cardiology literature. However, there are few cases reported in the pediatric population. Seizure is a presentation common to pediatric emergency departments. This case report describes the clinical course, workup, and differential diagnosis of a 15-year-old male adolescent with first-time seizure and Brugada pattern on electrocardiogram. A brief review of the literature follows the case presentation.

Secondary Headaches in Children and Adolescents: What Not to Miss

INTRODUCTION

Headaches are a common occurrence in childhood and adolescence. Most children presenting with a chief complaint of headache have a self-limited infectious disorder or primary headache syndrome that should not require extensive workup.

PURPOSE OF REVIEW

Differentiating these conditions from other more serious causes of headache in children can sometimes be difficult. This article aims to provide information regarding "red flags" that should indicate a need for concern for disorders that require more urgent evaluation.

RECENT FINDINGS

Long-held beliefs about specific "red flags" that have been analyzed in recent years as to their validity and new criteria for the diagnosis of idiopathic intracranial hypertension have been elaborated based on study. These publications are reviewed in this article. Knowledge of past and current literature on secondary headache in children, combined with thorough history taking and examination, should help determine when there is concern for a serious secondary cause for headache in children and adolescents and direct workup.

Advocacy for children with epilepsy: Leveraging the WHA resolution. Advocacy Task Force, Commission of Pediatrics, International League Against Epilepsy

In May 2015 the World Health Assembly (WHA) approved the Resolution on the Global Burden of Epilepsy. This report addresses how the Resolution can be leveraged to improve the care of children with epilepsy worldwide. Children with epilepsy have unique needs and face unique challenges from stigma at all levels of society. Children lack a voice to lobby for their own needs, including their right to have access to education. Effective leadership and governance should be enhanced through the support of stakeholders empowered to counsel, advise, and lobby for appropriate care. National health care plans should integrate primary and specialist care, and they need to be adapted to local specificities. Antiepileptic medicines should be widely accessible in appropriate, sustained, and affordable ways. Public awareness initiatives are needed to improve the inclusion of affected children in society and to reduce stigma. Cost-effective interventions are also needed to address preventable causes of epilepsy. Without greater investment in research, evidence-based interventions cannot be implemented. Through all of this, civil society must be engaged to ensure that the multivariate dimensions from the clinic to the community are addressed to fulfil the needs of children with epilepsy.

Epilepsy

Epilepsy affects all age groups and is one of the most common and most disabling neurological disorders. The accurate diagnosis of seizures is essential as some patients will be misdiagnosed with epilepsy, whereas others will receive an incorrect diagnosis. Indeed, errors in diagnosis are common, and many patients fail to receive the correct treatment, which often has severe consequences. Although many patients have seizure control using a single medication, others require multiple medications, resective surgery, neuromodulation devices or dietary therapies. In addition, one-third of patients will continue to have uncontrolled seizures. Epilepsy can substantially impair quality of life owing to seizures, comorbid mood and psychiatric disorders, cognitive deficits and adverse effects of medications. In addition, seizures can be fatal owing to direct effects on autonomic and arousal functions or owing to indirect effects such as drowning and other accidents. Deciphering the pathophysiology of epilepsy has advanced the understanding of the cellular and molecular events initiated by pathogenetic insults that transform normal circuits into epileptic circuits (epileptogenesis) and the mechanisms that generate seizures (ictogenesis). The discovery of >500 genes associated with epilepsy has led to new animal models, more precise diagnoses and, in some cases, targeted therapies.

Imaging Gently

Advances in medical imaging are invaluable in the care of pediatric patients in the emergent setting. The diagnostic accuracy offered by studies using ionizing radiation, such as plain radiography, computed tomography, and fluoroscopy, are not without inherent risks. This article reviews the evidence supporting the risk of ionizing radiation from medical imaging as well as discusses clinical scenarios in which clinicians play an important role in supporting the judicious use of imaging studies.

Getting serious about the early-life epilepsies

Early-life epilepsies represent a group of many individually rare and often complex developmental brain disorders associated with lifelong devastating consequences and high risk for early mortality. The quantity and quality of evidence needed to guide the evaluation and treatment to optimize outcomes of affected children is minimal; most children are treated within an evidence-free practice zone based solely on anecdote and lore. The remarkable advances in diagnostics and therapeutics are implemented haphazardly with no systematic effort to understand their effects and value. This stands in stark contrast to the evidence-rich practice of the Children's Oncology Group, where standard of care treatments are identified through rigorous, multicenter research studies, and the vast majority of patients are treated on protocols developed from that research. As a consequence, overall mortality for childhood cancers has declined from ∼90% in the 1950s to ∼20% today. The situations of these 2 rare disease specialties are contrasted, and some suggestions for moving early-life epilepsy onto a fast track for success are offered. Chief amongst these is that early-life epilepsy should be treated with the same urgency as pediatric cancer. The best diagnostics and evidence-based treatments should be used in a systematic fashion right from the start, not after the child and family have been subjected to the ravages of the disorder for months or years. This will require unity and cooperation among physicians, researchers, and institutions across state and national borders.

Early Recurrence of First Unprovoked Seizures in Children

OBJECTIVES

The risk of early seizure recurrences after first unprovoked seizures in children is largely unknown. We aimed to determine the rate of seizure recurrence within 14 days of first unprovoked seizures in children and identify associated risk factors. Secondarily, we aimed to determine the risk of recurrence at 48 hours and 4 months.

METHODS

We conducted a secondary analysis of a multicenter cohort study of children 29 days to 18 years with first unprovoked seizures. Emergency department (ED) clinicians completed standardized histories and physical examinations. The primary outcome, recurrent seizure at 14 days, and the secondary outcomes, recurrence at 48 hours and 4 months, were assessed by telephone follow-up and medical record review. For each recurrence time point, we excluded those patients for whom no seizure had recurred but chronic antiepileptic drugs had been initiated.

RESULTS

A total of 475 patients were enrolled in the parent study. Of evaluable patients for this secondary analysis, 26 of 392 (6.6%, 95% confidence interval [CI] = 4.4%-9.6%) had recurrences within 48 hours of the incident seizures, 58 of 366 (15.8%, 95% CI = 12.3%-20.0%) had recurrences within 14 days, and 107 of 340 (31.5%, 95% CI = 26.6%-36.7%) had recurrences within 4 months. On logistic regression analysis, age younger than 3 years was independently associated with a higher risk of 14-day recurrence (adjusted odds ratio [OR] = 2.1, 95% CI = 1.2-3.7; p = 0.01). Having had more than one seizure within the 24 hours prior to ED presentation was independently associated with a higher risk of seizure recurrence at 48 hours (adjusted OR = 4.3, 95% CI = 1.9-9.8; p < 0.001).

CONCLUSIONS

Risk of seizure recurrence 14 days after first unprovoked seizures in children is substantial, with younger children at higher risk. Prompt completion of an electroencephalogram and evaluation by a neurologist is appropriate for these children.

Systematic Review and Meta-analysis of Seizure Recurrence After a First Unprovoked Seizure in 815 Neurologically and Developmentally Normal Children

Limited data exist for health care providers regarding seizure recurrence after a first unprovoked seizure in previously neurologically and developmentally normal children. A systematic review and meta-analysis was conducted to assess seizure recurrence after a first unprovoked seizure by performing an electronic search in PubMed, Embase, and Scopus. Six studies from 2817 met the inclusion criteria. The sample size consisted of 815 neurologically and developmentally normal children (1 month-17.5 years) on no antiepileptic drugs. This systematic review and meta-analysis estimated a recurrence rate within 3 years of 45% (95% CI: 37%, 60%). This estimate provides a touchstone for health care providers who are managing this particular population of children.

Management protocols for status epilepticus in the pediatric emergency room: systematic review article

OBJECTIVE

This systematic review of national or regional guidelines published in English aimed to better understand variance in pre-hospital and emergency department treatment of status epilepticus.

SOURCES

Systematic search of national or regional guidelines (January 2000 to February 2017) contained within PubMed and Google Scholar databases, and article reference lists. The search keywords were status epilepticus, prolonged seizure, treatment, and guideline.

SUMMARY OF FINDINGS

356 articles were retrieved and 13 were selected according to the inclusion criteria. In all six pre-hospital guidelines, the preferred route of medication administration was to use alternatives to the intravenous route: all recommended buccal and intranasal midazolam; three also recommended intramuscular midazolam, and five recommended using rectal diazepam. All 11 emergency department guidelines described three phases in therapy. Intravenous medication, by phase, was indicated as such: initial phase - ten/11 guidelines recommended lorazepam, and eight/11 recommended diazepam; second phase - most (ten/11) guidelines recommended phenytoin, but other options were phenobarbital (nine/11), valproic acid (six/11), and either fosphenytoin or levetiracetam (each four/11); third phase - four/11 guidelines included the choice of repeating second phase therapy, whereas the other guidelines recommended using a variety of intravenous anesthetic agents (thiopental, midazolam, propofol, and pentobarbital).

CONCLUSIONS

All of the guidelines share a similar framework for management of status epilepticus. The choice in route of administration and drug type varied across guidelines. Hence, the adoption of a particular guideline should take account of local practice options in health service delivery.

EEG for children with complex febrile seizures

BACKGROUND

Febrile seizures can be classified as simple or complex. Complex febrile seizures are associated with fever that lasts longer than 15 minutes, occur more than once within 24 hours, and are confined to one side of the child's body. It is common in some countries for doctors to recommend an electroencephalograph (EEG) for children with complex febrile seizures. A limited evidence base is available to support the use of EEG and its timing after complex febrile seizures among children.

OBJECTIVES

To assess the use of EEG and its timing after complex febrile seizures in children younger than five years of age.

SEARCH METHODS

For the latest update of this review, we searched the Cochrane Epilepsy Group Specialized Register (23 January 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (CRSO, 23 January 2017), MEDLINE (Ovid, 23 January 2017), and ClinicalTrials.gov (23 January 2017). We applied no language restrictions.

SELECTION CRITERIA

All randomised controlled trials (RCTs) that examined the utility of an EEG and its timing after complex febrile seizures in children.

DATA COLLECTION AND ANALYSIS

The review authors selected and retrieved the articles and independently assessed which articles should be included. Any disagreements were resolved by discussion and by consultation with the Cochrane Epilepsy Group. We applied standard methodological procedures expected by Cochrane.

MAIN RESULTS

Of 41 potentially eligible studies, no RCTs met the inclusion criteria.

AUTHORS' CONCLUSIONS

We found no RCTs as evidence to support or refute the use of EEG and its timing after complex febrile seizures among children. An RCT can be planned in such a way that participants are randomly assigned to the EEG group and to the non-EEG group with sufficient sample size. Since the last version of this review, we have found no new studies.

Early-Life Epilepsies and the Emerging Role of Genetic Testing

IMPORTANCE

Early-life epilepsies are often a consequence of numerous neurodevelopmental disorders, most of which are proving to have genetic origins. The role of genetic testing in the initial evaluation of these epilepsies is not established.

OBJECTIVE

To provide a contemporary account of the patterns of use and diagnostic yield of genetic testing for early-life epilepsies.

DESIGN, SETTING, AND PARTICIPANTS

In this prospective cohort, children with newly diagnosed epilepsy with an onset at less than 3 years of age were recruited from March 1, 2012, to April 30, 2015, from 17 US pediatric hospitals and followed up for 1 year. Of 795 families approached, 775 agreed to participate. Clinical diagnosis of the etiology of epilepsy were characterized based on information available before genetic testing was performed. Added contributions of cytogenetic and gene sequencing investigations were determined.

EXPOSURES

Genetic diagnostic testing.

MAIN OUTCOMES AND MEASURES

Laboratory-confirmed pathogenic variant.

RESULTS

Of the 775 patients in the study (367 girls and 408 boys; median age of onset, 7.5 months [interquartile range, 4.2-16.5 months]), 95 (12.3%) had acquired brain injuries. Of the remaining 680 patients, 327 (48.1%) underwent various forms of genetic testing, which identified pathogenic variants in 132 of 327 children (40.4%; 95% CI, 37%-44%): 26 of 59 (44.1%) with karyotyping, 32 of 188 (17.0%) with microarrays, 31 of 114 (27.2%) with epilepsy panels, 11 of 33 (33.3%) with whole exomes, 4 of 20 (20.0%) with mitochondrial panels, and 28 of 94 (29.8%) with other tests. Forty-four variants were identified before initial epilepsy presentation. Apart from dysmorphic syndromes, pathogenic yields were highest for children with tuberous sclerosis complex (9 of 11 [81.8%]), metabolic diseases (11 of 14 [78.6%]), and brain malformations (20 of 61 [32.8%]). A total of 180 of 446 children (40.4%), whose etiology would have remained unknown without genetic testing, underwent some testing. Pathogenic variants were identified in 48 of 180 children (26.7%; 95% CI, 18%-34%). Diagnostic yields were greater than 15% regardless of delay, spasms, and young age. Yields were greater for epilepsy panels (28 of 96 [29.2%]; P < .001) and whole exomes (5 of 18 [27.8%]; P = .02) than for chromosomal microarray (8 of 101 [7.9%]).

CONCLUSIONS AND RELEVANCE

Genetic investigations, particularly broad sequencing methods, have high diagnostic yields in newly diagnosed early-life epilepsies regardless of key clinical features. Thorough genetic investigation emphasizing sequencing tests should be incorporated into the initial evaluation of newly presenting early-life epilepsies and not just reserved for those with severe presentations and poor outcomes.

Diagnostic and Therapeutic Management of a First Unprovoked Seizure in Children and Adolescents With a Focus on the Revised Diagnostic Criteria for Epilepsy

By definition, unprovoked seizures are not precipitated by an identifiable factor, such as fever or trauma. A thorough history and physical examination are essential to caring for pediatric patients with a potential first unprovoked seizure. Differential diagnosis, EEG, neuroimaging, laboratory tests, and initiation of treatment will be reviewed. Treatment is typically initiated after 2 unprovoked seizures, or after 1 seizure in select patients with distinct epilepsy syndromes. Recent expansion of the definition of epilepsy by the ILAE allows for the diagnosis of epilepsy to be made after the first seizure if the clinical presentation and supporting diagnostic studies suggest a greater than 60% chance of a second seizure. This review summarizes the current literature on the diagnostic and therapeutic management of first unprovoked seizure in children and adolescents while taking into consideration the revised diagnostic criteria of epilepsy.

Clinicodemographic Profile of Children with Seizures in a Tertiary Care Hospital: A Cross-Sectional Observational Study

Seizures are one of the common causes for hospital admissions in children with significant mortality and morbidity. This study was conducted to study the prevalence and clinicodemographic profile of children with seizures in a tertiary care hospital of western Nepal. This prospective cross-sectional study conducted over a period of 2 years included all admitted children (2 months-16 years) with seizures. Among 4962 admitted children, seizures were present in 3.4% (n = 168) of children, with male preponderance. 138 (82.1%) children had generalized tonic-clonic seizures (GTCS) and 30 (17.9%) children had partial seizures. GTCS were more common than partial seizures in both sexes (male = 82.7%; female = 81.2%) and age groups. There was no statistical significance in the distribution of seizures (GTCS and partial seizures) with sexes (P = 0.813) and age groups (P = 0.955). Mean ages of children having GTCS and partial seizures were 8.2 ± 4.6 years and 8.2 ± 4.2 years, respectively. Loss of consciousness (55.4%), fever (39.9%), vomiting (35.1%), and headache (16.1%) were common complaints in seizure patients. Significant number of GTCS cases had fever (P = 0.041) and neurocysticercosis (n = 72; 43%) was the most common etiology in seizure patients. Idiopathic epilepsy (38 (22.6%)), meningoencephalitis (26 (15.5%)), and febrile convulsions (14 (8.33%)) were other leading disorders in children with seizures.

Risk of recurrence after a first unprovoked seizure in children

OBJECTIVES

This study aimed to evaluate the first episode of unprovoked epileptic seizure in children and assess recurrence risk factors.

METHODS

This was a retrospective observational study, based on the analysis of medical records of patients admitted between 2003 and 2014, with first epileptic seizure, at the pediatric service of a secondary hospital. The data were analyzed using the SPSS 20.0 program.

RESULTS

Of the 103 patients, 52.4% were boys. The median age at the first seizure was 59 (1-211) months. About 93% of children were submitted to an electroencephalogram at the first episode and 47% underwent neuroimaging assessment. Treatment with an antiepileptic drug was started in 46% of patients. The recurrence rate was 38% and of these, 80% had the second seizure within six months after the first event. Of the assessed risk factors, there was a statistically significant association between seizure during sleep and recurrence (p=0.004), and between remote symptomatic etiology seizure and occurrence of new seizure (p=0.02). The presence of electroencephalogram abnormalities was also associated with the occurrence of new seizures (p=0.021). No association was found between age, duration of the seizure, and family history of epilepsy with increased risk of recurrence.

CONCLUSIONS

Most children with a first unprovoked epileptic seizure had no recurrences. The risk of recurrence was higher in patients with seizure occurring during sleep or remote symptomatic ones and those with abnormal electroencephalogram results.

MRI Utilization and the Associated Use of Sedation and Anesthesia in a Pediatric ACO

BACKGROUND AND OBJECTIVES

MRI is commonly used in the pediatric population and often requires sedation or general anesthesia to complete. This study used data from a pediatric accountable care organization (ACO) to investigate trends in MRI utilization and in the requirement for anesthesia to complete MRI examinations.

METHODS

The Partners for Kids (PFK) ACO claims database was queried for MRI examination encounters involving patients 0 to 18 years old from 2009 to 2014, with utilization expressed as encounters per 10,000 PFK members-months. Data were limited to 2011 to 2014 to ensure consistent billing of anesthesia services. Encounters were classified according to the presence of procedure codes for anesthesia or sedation.

RESULTS

MRI utilization was approximately constant over the study period at 11 to 12 encounters per 10,000 member-months. The need for anesthesia increased from 21% to 28% of encounters over 2011 to 2014. The latter increase was shared across 1- to 6-year-old, 7- to 12-year-old, and 12- to 18-year-old subgroups. In multivariable regression analysis of monthly utilization, increasing need for anesthesia could not be attributed to secular trends in patient demographics or types of examinations ordered. Paid cost data were available for outpatient MRIs, and MRIs with sedation accounted for an increasing share of these costs (from 22% in 2011 to 33% in 2014).

CONCLUSION

There was an increasing need for anesthesia services to complete MRI examinations in this pediatric population, resulting in increasing cost of MRI examinations and presenting a challenge to ACO cost containment.

Cerebrospinal fluid analysis after unprovoked first seizure

The aim of this study was to determine cerebrospinal fluid (CSF) characteristics after an unprovoked first seizure (UFS). We reviewed the medical records of 71 patients with UFS who underwent lumbar puncture, and examined the CSF parameters. Each CSF parameter was evaluated separately for potential correlations with the other study variables. We observed an overall frequency of CSF abnormalities of 35.2%. CSF protein was the most common abnormal parameter (31%) and showed significant positive correlations with male gender (p=0.037) and older age (p=0.007). Only seven patients (9.9%) had an abnormal cell count (5-40 cells/μl). Higher CSF cell counts were found to predict a longer hospitalization period (p=0.005). No relationship with abnormal EEG findings could be established (p=0.169). This study is one of the few to evaluate postictal CSF parameters in a clinical setting, and to our knowledge the first to investigate these parameters specifically in the emergency department. The development of a rapid, easy-to-use test that does not require extensive laboratory equipment to differentiate UFS from other conditions could be of great value in everyday clinical practice.

Radiation dose reduction using 100-kVp and a sinogram-affirmed iterative reconstruction algorithm in adolescent head CT: Impact on grey-white matter contrast and image noise

OBJECTIVES

To retrospectively evaluate the image quality and radiation dose of 100-kVp scans with sinogram-affirmed iterative reconstruction (IR) for unenhanced head CT in adolescents.

METHODS

Sixty-nine patients aged 12-17 years underwent head CT under 120- (n = 34) or 100-kVp (n = 35) protocols. The 120-kVp images were reconstructed with filtered back-projection (FBP), 100-kVp images with FBP (100-kVp-F) and sinogram-affirmed IR (100-kVp-S). We compared the effective dose (ED), grey-white matter (GM-WM) contrast, image noise, and contrast-to-noise ratio (CNR) between protocols in supratentorial (ST) and posterior fossa (PS). We also assessed GM-WM contrast, image noise, sharpness, artifacts, and overall image quality on a four-point scale.

RESULTS

ED was 46% lower with 100- than 120-kVp (p < 0.001). GM-WM contrast was higher, and image noise was lower, on 100-kVp-S than 120-kVp at ST (p < 0.001). CNR of 100-kVp-S was higher than of 120-kVp (p < 0.001). GM-WM contrast of 100-kVp-S was subjectively rated as better than of 120-kVp (p < 0.001). There were no significant differences in the other criteria between 100-kVp-S and 120-kVp (p = 0.072-0.966).

CONCLUSIONS

The 100-kVp with sinogram-affirmed IR facilitated dramatic radiation reduction and better GM-WM contrast without increasing image noise in adolescent head CT.

KEY POINTS

• 100-kVp head CT provides 46% radiation dose reduction compared with 120-kVp. • 100-kVp scanning improves subjective and objective GM-WM contrast. • Sinogram-affirmed IR decreases head CT image noise, especially in supratentorial region. • 100-kVp protocol with sinogram-affirmed IR is suited for adolescent head CT.

Neuro-imaging evaluation after the first afebrile seizure in children: A retrospective observational study

PURPOSE

To evaluate the role of neuro-imaging in children presenting with the first afebrile seizure and determine factors that influence the outcome of imaging in a large paediatric emergency centre.

METHOD

This is a retrospective review of the medical records of all patients presenting with the first non-febrile seizure to a large paediatric emergency centre in the state of Qatar. Seizure classification followed the current ILAE classification system. Imaging was undertaken in our tertiary hospital and all images were reviewed by experienced neuro-radiologists. Student t test was used for statistical analysis.

RESULTS

Ninety-six children underwent neuro-imaging following the first afebrile seizure. Of them, thirty-two patients (33%) were reported to have abnormalities. Children below the age of two demonstrated a significantly higher percentage of abnormal imaging (59%); (p=0.002). Children presenting with prolonged seizures showed a high percentage of imaging abnormalities (58%); (p=0.003). Children with focal seizures demonstrated a higher percentage of imaging abnormality compared to those presenting with generalized seizures (35% vs 31%). This difference did not reach statistical significance.

CONCLUSION

Children below the age of two demonstrated significantly higher percentages of abnormal imaging (59%), as did children presenting with status epilepticus (58%). Neuro-imaging should be considered in infants and those with focal or prolonged seizures. Neuro-imaging informed decision making in 6-8% of children.

[Predictors of epilepsy in children after ischemic stroke]

AIM

To determine clinical/instrumental predictors of symptomatic epilepsy after ischemic stroke in children.

MATERIAL AND METHODS

One hundred and thirty-six patients, aged 0-15 years, with the diagnosis of ischemic stroke (ICD-10 I63.0-I63.9) were examined. The duration of the study was 18 months - 12 years. Patients were stratified into post-stroke (n=22) and control (n=114) groups, the latter included patients without epilepsy regardless of the presence of convulsive seizures in the acute stage of stroke. Predictors were determined based on EEG and characteristics of convulsive syndrome in the acute stage of stroke.

RESULTS AND CONCLUSION

The following prognostic criteria were found: generalized type of seizures, focal type of seizures with secondary generalization, epileptiform (peak and/or peak-wave) activity, focal character of epileptiform activity, generalized type of seizures in the combination with slow wave background activity on EEG, generalized type of seizures in the combination with slow wave activity and disorganized activity on EEG.

Evaluation of an E-learning resource on approach to the first unprovoked seizure

AIM

To develop and evaluate an online educational package instructing paediatricians and trainees in the diagnosis and management of a first unprovoked seizure in children.

METHODS

The E-learning content was created following a comprehensive literature review that referenced current international guidelines. Rigorous consultation with local paediatric neurologists, paediatricians and epilepsy nurses was undertaken. A series of learning modules was created and sequenced to reflect steps needed to achieve optimal diagnosis and management in a real-life situation of a child presenting with a paroxysmal event. Paediatric registrars and advanced trainees from the Sydney Children's Hospitals Network were assessed before and after using the E-learning Resource. Measures included general epilepsy knowledge, case-based scenario knowledge; self-rated measures of satisfaction with instruction and confidence regarding clinical approach to the child with first unprovoked seizure; and open ended questions evaluating the usefulness of the E-learning resource.

RESULTS

Performance on measures of general epilepsy knowledge and on the seizure-related case scenarios improved significantly following completion of the E-learning as did self-rated satisfaction with instruction and confidence across all aspects of managing first seizure.

CONCLUSIONS

The E-learning resource has been validated as a useful educational resource regarding the first afebrile unprovoked seizure for paediatricians.

Profile and clinical characterization of seizures in hospitalized children

INTRODUCTION

Seizure is the commonest pediatric neurological disorder, which is frightening to caretakers. The current study aims to determine profile, clinical spectrum and analyze the commonest etiology of seizures in children admitted to a tertiary hospital in Central China.

METHODS

This was a hospital based retrospective study carried out in Zhongnan Hospital of Wuhan University, China. Computerized data was collected from January 2012 to May 2015. Variables collected were demographics, clinical presentations and laboratory tests; brain imaging studies, electroencephalography, diagnosis, prognosis, outcome and duration of hospitalization.

RESULTS

A total of 200 patients were admitted with seizures. There were 109 (54.5%) males and 91 (45.5%) females. Among these patients, 193 (96.5%) were aged 1 month to 5 years and 182 (91.0%) presented with seizures and fever. Generalized tonic-clonic seizure was the most common seizure type in 196 (98.0%) children. Febrile seizure was the leading etiology of seizure in 175 (87.5%) children followed by epilepsy in 11 (5.5%) children. There were only 3 (2%) children with central nervous system infections. Abnormal brain images were noted in 10 (20%) out of 50 patients. Among 193 children tested for different infections, 49 (25.4%) had positive results. Viral infections were commonest infections by 49.0%, atypical bacterial 34.7% and 16.3% coinfections.

CONCLUSION

Seizure was the commonest neurological condition of children admitted in our hospital, febrile seizures being the commonest etiology. The prognosis and outcomes were good but there were prolonged days of hospitalization. Children with unprovoked seizures require brain-imaging studies for better understanding of seizure etiology.

Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants

This is the first clinical practice guideline from the American Academy of Pediatrics that specifically applies to patients who have experienced an apparent life-threatening event (ALTE). This clinical practice guideline has 3 objectives. First, it recommends the replacement of the term ALTE with a new term, brief resolved unexplained event (BRUE). Second, it provides an approach to patient evaluation that is based on the risk that the infant will have a repeat event or has a serious underlying disorder. Finally, it provides management recommendations, or key action statements, for lower-risk infants. The term BRUE is defined as an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of ≥1 of the following: (1) cyanosis or pallor; (2) absent, decreased, or irregular breathing; (3) marked change in tone (hyper- or hypotonia); and (4) altered level of responsiveness. A BRUE is diagnosed only when there is no explanation for a qualifying event after conducting an appropriate history and physical examination. By using this definition and framework, infants younger than 1 year who present with a BRUE are categorized either as (1) a lower-risk patient on the basis of history and physical examination for whom evidence-based recommendations for evaluation and management are offered or (2) a higher-risk patient whose history and physical examination suggest the need for further investigation and treatment but for whom recommendations are not offered. This clinical practice guideline is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient outcomes, support implementation, and provide direction for future research. Each key action statement indicates a level of evidence, the benefit-harm relationship, and the strength of recommendation.

Seizure Recurrence in Developmentally and Neurologically Normal Children With a Newly Diagnosed Unprovoked Seizure

This study aims to assess recurrence risk in developmentally and neurologically normal children with a newly diagnosed unprovoked seizure. The medical record was retrospectively reviewed in 393 children who had a newly diagnosed, unprovoked seizure. A total of 152 children met inclusion criteria. The relationship between seizure recurrence and variables was examined. Seventy cases had recurrent seizures. Total 113 cases had follow-up data and 70 cases of these (63.7%) experienced recurrent seizures. EEG was abnormal in 65 (44.8%): focal epileptiform abnormality in 34 cases (23.4%) and generalized epileptiform abnormality in 23 cases (15.9%). Brain MRI revealed any structural abnormality in 14 of 86 cases (16.3%). Neither EEG abnormality nor brain MRI abnormality was statistically significantly associated with increased seizure recurrence in this cohort. Further study is required to confirm the EEG and brain MRI findings in otherwise normal children with a newly diagnosed unprovoked seizure.

Focal seizure associated with human parvovirus B19 infection in a non-encephalopathic child

BACKGROUND

The incidence of acute symptomatic (at the time of documented brain insult) seizures and single unprovoked seizures are 29-39 and 23-61 per 100 000 per year, respectively. After stabilization of the patient, finding the etiology of the seizure is of paramount importance. A careful history and physical examination may allow a diagnosis without need for further evaluation.

METHODS

In the literature, severe central nervous system involvement has been reported from human parvovirus B19 infection. We reported a previously healthy 7-year-old girl who presented after an episode of focal seizure. She was afebrile and didn't have any focal neurological abnormalities. She had erythematous malar rash along with reticulating pattern of rash over her both upper extremities.

RESULTS

Parvovirus infection was suspected due to the characteristic erythematous malar rash. Serum human parvovirus B19 DNA polymerase chain reaction was positive which was consistent with acute parvovirus infection. Further confirmation of current infection was done with Sandwich enzyme immunoassays showing positive anti-B19 IgM Index (>1.1). IgG index was equivocal (0.9-1.1).

CONCLUSIONS

We report an extremely rare presentation of non-febrile seizure from acute parvovirus infection in a child without encephalopathy who had an excellent recovery. Timely diagnosis can provide counselling regarding future seizure recurrence risk, curtail expenditure from expensive diagnostic work up and provide additional recommendations about potential risks to a pregnant caregiver.

Acute Symptomatic Seizures Caused by Electrolyte Disturbances

In this narrative review we focus on acute symptomatic seizures occurring in subjects with electrolyte disturbances. Quite surprisingly, despite its clinical relevance, this issue has received very little attention in the scientific literature. Electrolyte abnormalities are commonly encountered in clinical daily practice, and their diagnosis relies on routine laboratory findings. Acute and severe electrolyte imbalances can manifest with seizures, which may be the sole presenting symptom. Seizures are more frequently observed in patients with sodium disorders (especially hyponatremia), hypocalcemia, and hypomagnesemia. They do not entail a diagnosis of epilepsy, but are classified as acute symptomatic seizures. EEG has little specificity in differentiating between various electrolyte disturbances. The prominent EEG feature is slowing of the normal background activity, although other EEG findings, including various epileptiform abnormalities may occur. An accurate and prompt diagnosis should be established for a successful management of seizures, as rapid identification and correction of the underlying electrolyte disturbance (rather than an antiepileptic treatment) are of crucial importance in the control of seizures and prevention of permanent brain damage.

Neuroimaging Evaluation for First Attack of Unprovoked Nonfebrile Seizure in Pediatrics: When to Order?

OBJECTIVE

To assess the value of neuroimaging studies in evaluating pediatric patients presenting with a first attack of nonfebrile seizure.

METHOD

We reviewed the medical records of pediatric patients aged 28 days to 12 years who were admitted between 1 January and 31 December 2013 with a first attack of unprovoked, afebrile seizure. These patients had undergone neuroimaging studies. The exclusion criterion was patients with known predisposing conditions for seizure. The computed tomography (CT) scan and magnetic resonance imaging (MRI) results were either normal or abnormal, and the abnormal ones were further classified into clinically insignificant or significant. Descriptive analysis was performed to summarize the data.

RESULT

Fifty children were identified with a mean age of 5.2 ± 3.8 years. Of the 50 subjects, 29 (58.0%) were males and 21 (42.0%) were females. Sixteen patients (32.0%) had abnormal neuroimaging studies (CT scan, MRI or both); however, only 1 was considered to have a clinically significant abnormality, later diagnosed as Moyamoya disease.

CONCLUSION

In this study, the neuroimaging studies were found not to be useful in evaluating pediatric patients presenting with a first attack of unprovoked, nonfebrile seizures.

Yield of emergent neuroimaging in children with new-onset seizure and status epilepticus

PURPOSE

To determine the yield of emergent neuroimaging among children with new-onset seizures presenting with status epilepticus.

METHOD

We performed a cross-sectional study of children seen at a single ED between 1995 and 2012 with new-onset seizure presenting with status epilepticus. We defined status epilepticus as a single seizure or multiple seizures without regaining consciousness lasting 30 min or longer. Our primary outcome was urgent or emergent intracranial pathology identified on neuroimaging. We categorized neuroimaging results as emergent if they would have changed acute management as assessed by a blinded neuroradiologist and neurologist. To ensure abnormalities were not missed, we review neuroimaging results for 30 days following the initial episode of SE.

RESULTS

We included 177 children presenting with new-onset seizure with status epilepticus, of whom 170 (96%) had neuroimaging performed. Abnormal findings were identified on neuroimaging in 64/177 (36%, 95% confidence interval 29-43%) children with 15 (8.5%, 95% confidence interval 5.2-14%) children having urgent or emergent pathology. Four (27%) of the 15 children with urgent or emergent findings had a normal non-contrast computed tomography scan and a subsequently abnormal magnetic resonance image. Longer seizure duration and older age were associated with urgent or emergent intracranial pathology.

CONCLUSION

A substantial minority of children with new-onset seizures presenting with status epilepticus have urgent or emergent intracranial pathology identified on neuroimaging. Clinicians should strongly consider emergent neuroimaging in these children. Magnetic resonance imaging is the preferred imaging modality when available and safe.

EEG for children with complex febrile seizures

BACKGROUND

This is an updated version of original Cochrane review published in Issue 1, 2014.Febrile seizures can be classified as simple or complex. Complex febrile seizures are associated with fever that lasts longer than 15 minutes, occur more than once within 24 hours and are confined to one side of the child's body. It is common in some countries for doctors to recommend an electroencephalograph (EEG) for children with complex febrile seizures. A limited evidence base is available to support the use of EEG and its timing after complex febrile seizures among children.

OBJECTIVES

To assess the use of EEG and its timing after complex febrile seizures in children younger than five years of age.

SEARCH METHODS

For the latest update of this review, we searched the Cochrane Epilepsy Group Specialized Register (6 July 2015), the Cochrane Central Register of Controlled Trials (CENTRAL, 2005, Issue 6), MEDLINE (6 July 2015) and ClinicalTrials.gov (6 July 2015). We applied no language restrictions.

SELECTION CRITERIA

All randomised controlled trials (RCTs) that examined the utility of an EEG and its timing after complex febrile seizures in children.

DATA COLLECTION AND ANALYSIS

Review authors selected and retrieved the articles and independently assessed which articles should be included. We resolved disagreements by discussion and by consultation with the Cochrane Epilepsy Group. We applied standard methodological procedures expected by Cochrane.

MAIN RESULTS

Of 37 potentially eligible studies, no RCTs met the inclusion criteria.

AUTHORS' CONCLUSIONS

We found no RCTs as evidence to support or refute the use of EEG and its timing after complex febrile seizures among children. An RCT can be planned in such a way that participants are randomly assigned to the EEG group and to the non-EEG group with sufficient sample size. Since the last version of this review, we found no new studies.

Signs and symptoms of pediatric brain tumors and diagnostic value of preoperative EEG

In pediatric patients, brain tumors have been estimated to be the cause for seizures in only 0.2-0.3% of cases, whereas seizures occurred in about 13% of pediatric brain tumor patients at presentation. This survey was conducted to analyze EEG findings in pediatric tumor patients over the past 14 years to evaluate the diagnostic value of preoperative EEG for diagnosis of brain tumors. Surface EEG was obtained in awake patients using the international 10- to 20-electrode placement in all pediatric patients with intracranial neoplasms between 2000 and 2013 at the University Hospital of Leipzig except for those who needed emergency operative treatment. One hundred forty-two pediatric patients with 80 infratentorial and 62 supratentorial tumors (WHO grades I-II: 91 patients; WHO grades III-IV: 46 patients). Symptomatic hydrocephalus was found in 37. Sensitivity and specificity of ophthalmologic examination for predicting hydrocephalus was 0.39 and 0.72. Preoperative EEG has been conducted in 116 patients, showing normal activity in 54 patients (47%). Out of 62 pathologic EEGs, 40 indicated correctly to the site of the lesion, 15 were pathologic despite of infratentorial location of the tumor. Nineteen patients had a history of seizures of which six had normal EEGs. Sensitivity for and specificity of EEG examination for symptomatic epilepsy was 0.68 and 0.7. Conclusion Preoperative routine EEG provides no additional value in the diagnostic algorithm of pediatric train tumors. The low specificity and sensitivity of EEG (even in patients with clinical seizures as primary symptom of a brain tumor) underline that EEG does not contribute to diagnosis and a normal EEG might even delay correct diagnosis.

Predictors of Abnormal Neuroimaging of the Brain in Children With Epilepsy Aged 1 Month to 2 Years: Useful Clues in a Resource-Limited Setting

Neuroimaging should be performed on infants with seizure. However, there are economic limitations in performing neuroimaging in a resource-limited setting. The younger the age, the higher the risk of having abnormal neuroimaging. The aim was to determine frequency and predictors of abnormal neuroimaging in children with epilepsy aged 1 month to 2 years. History, physical examination, electroencephalogram (EEG), and neuroimaging were reviewed. Thirty-seven of 49 (76%) had neuroimaging studies; 19 computed tomography (CT), 14 magnetic resonance imaging (MRI), and 4 had both. Abnormal neuroimaging was found in 19 (51%). Predictors of abnormal neuroimages are developmental delay, abnormal head circumference, and abnormal neurologic examination. Eight children (21%) had lesions on neuroimaging studies that altered or influenced management. Of 8 patients with normal examination and EEG, 1 had a brain tumor and another had arteriovenous malformation. Neuroimaging should be considered as an essential aid in the evaluation of infants with epilepsy, even in a resource-limited setting.

Emergency Department Management of Pediatric Unprovoked Seizures and Status Epilepticus in the State of Illinois

The purpose of this survey and record review was to characterize emergency department management of unprovoked seizures and status epilepticus in children in Illinois. The survey was sent to 119 participating emergency departments in the Emergency Medical Services for Children program; responses were received from 103 (88% response rate). Only 44% of the emergency departments had a documented protocol for seizure management. Only 12% of emergency departments had child neurology consultation available at all times. Record review showed that 58% of patients were discharged home, 26% were transferred to another institution, and 10% were admitted to a non-intensive care unit setting. Ninety percent of patients were treated with anticonvulsants. Seizure education was provided by the primary emergency department nurse (97%) and the treating physician (79%). This project demonstrated strengths and weaknesses in the current management of pediatric seizure patients in Illinois emergency departments.

Computed Tomography and Shifts to Alternate Imaging Modalities in Hospitalized Children

BACKGROUND

Many studies have demonstrated a rise in computed tomography (CT) utilization in abstract children's hospitals. However, CT utilization may be declining, perhaps due to awareness of potential hazards of pediatric ionizing radiation, such as increased risk of malignancy. Th e objective is to assess the trend in CT utilization in hospitalized children at freestanding children's hospitals from 2004 to 2012 and we hypothesize decreases are associated with shifts to alternate imaging modalities.

METHODS

Multicenter cross-sectional study of children admitted to 33 pediatric tertiary-care hospitals participating in the Pediatric Health Information System between January 1, 2004, and December 31, 2012. The rates of CT, ultrasound, and MRI for the top 10 All-Patient Refined Diagnosis Related Groups (APR-DRGs) for which CT was performed in 2004 were determined by billing data. Rates of each imaging modality for those top 10 APR-DRGs were followed through the study period. Odds ratios of imaging were adjusted for demographics and illness severity.

RESULTS

For all included APR-DRGs except ventricular shunt procedures and nonbacterial gastroenteritis, the number of children imaged with any modality increased. CT utilization decreased for all APR-DRGs (P values , .001). For each of the APR-DRGs except seizure and infections of upper respiratory tract, the decrease in CT was associated with a significant rise in an alternative imaging modality (P values # .005).

CONCLUSIONS

For the 10 most common APR-DRGs for which children received CT in 2004,a decrease in CT utilization was found in 2012. Alternative imaging modalities for 8 of the diagnoses were used.