Microsoft powerpoint - febrile seizures.2012 contemp peds.ppt [compatibility mode]

Febrile Seizures……+
Educational needs
Febrile Seizures represent a major source anxiety for parents – and sometimes for understanding of the mechanisms underlying Disclosure
epidemiologic expert for the AAP committees that authored the Febrile Seizure Clinical child neurology consultant to the CDC committee on vaccines re: adverse neurological reactions Objectives
What is a Simple F. S.?
1. Seizure with fever >100.4 F2. In the absence of a CNS infection3 O 4. Lasts < 15 minutes and does not recur abnormality (including developmental delay) What is the outcome?
* No increase in mortality* No increase in mental retardation or * Subsequent risk of epilepsy is slightly increased
Background rate is about 1% (by age 25 yrs)
Simple FS rate is abut 2.5%
Major Risk of Simple FS
Child < 1 yr has a 50% recurrence risk
Child > 1 yr has a 30% recurrence risk
If you have 2 Simple FS, then the recurrence risk for a 3rd is 50%
Treatment of Simple FS
Benign outcomeNo evidence that any Rx will prevent the eventual development of epilepsy in the 2.5% Risk of Rx exceeds any reasonable
expectation of benefit
Diagnostic Testing
Lumbar Puncture: Obviously needed in any 6 to 12 months – LP if lacks Hib or Strep if child’s fever has no clear source, child has already received antibiotics, or any other situation where meningitis might be missed.
Tests that are not useful
EEGHead CT – a test to be avoided in childrenHead MRSerum electrolytes/glucose unless the child has sufficient diarrhea or other problem to justify the test regardless of Major Risk Factors
Viral infectionImmunizations: especially the old whole 1st degree relative who has had a febrile Why don’t we recommend?
Rx with antipyretics
In clinical trials they have not protected Experimental studies suggest that both fever and seizure are symptoms of the underlying pathophysiology of simple febrile seizures  They are fine for making children more Why do Febrile Seizures
immunization) triggers the body responses Heredity
 The major risk factor for having a simple febrile seizure is a 1st degree relative who  Rarely there is a known genetic variation associated with FS including abnormalities coding for: Na Channels GABAa receptors Interleukins Developmental Maturation
 Experimentally it is easier to cause  Immature brain has a different pattern of enzyme systems, for example – NKCC1 transporter Environment
The environmental events in FS all lead to WBC’s from children with febrile seizures can be more vigorous in Interleukin 1 release Brain microglia and astrocytes release Fever causes the production of Interleukin 1 Preventing Simple Febrile
Seizures
All of these data suggest that any effective Therapies, such as antipyretics, that do not Prolonged Febrile Seizures
Lasting >15 minutes or requiring acute Rx Temporal Sclerosis and intractable partial epilepsy have a history of a prolonged febrile seizure before age 5 years.
Children with MTS are often seizure free Mesial Temporal Sclerosis
HHV6 infection and MTS
By age 3 yr 90% of children have evidence Usually brief – child can be symptomatic for < 24 Children with HHV6 positive CSF can lack any WBC or other evidence of infection in their CSF MTS - ? Latent Viral
Infection
 Prospectively investigating children with  33% have been HHV6 positive (preliminary) A number have now shown early MTS progression of the temporal lobe sclerosis Hypothesis MTS/HHV6
A subset of these children have persisting HHV6 latency in their temporal lobe Some of these children have re-activation of  A permanent record should be kept of positives Other Possible Causes of
Cytokines cause temporal lobe changes and persistent seizures in animal models Prolonged febrile seizures can change:  Gene expression controlling ion channels, Specific transcription factors which alter  And other factors in experimental animals Levetiracetam: The
Pediatrician’s Friend
Partial complex epilepsyPrimary generalized tonic/clonic seizuresNot effective for juvenile absence epilepsy Easy to adjust – BID dosingLiquid and tabletsGeneric available (reasonable cost) Using Levetiracetam
Major side effect is cognitive/behavior Presents as hyperactivity/irritabilitySimply discontinue…no withdrawal seizures Usual y start low (10 to 20mg/kg/day)Increase slowly Until seizures stopDevelop side effectsReach 60 to 70 mg/kg/day Labs & Levetiracetam
None necessary – no organ damageRare allergyLevels seizures occur unexpectedly or in the face of

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