Seminar Week 5: Seminar Week 5 Can children with febrile convulsions be managed well in a rural clinic? Slide 2: Chihurumnanya Alo Omer Mandour Irphan Shammari Claire Uebbing Our brilliant team You are a newly trained medic, just assigned to your first post in rural Sudan: You are a newly trained medic, just assigned to your first post in rural Sudan And your first patient of the day, an 18 month old girl named Fatima is brought in by her anxious mother… “My daughter just had a fit!!!!”: “ My daughter just had a fit!!!! ” Fatima is an 18 month old girl, presenting after a convulsion of 5 min duration at home Her mother says the child had a fever today and was not feeding well, sleeping a lot She also noticed the child was coughing & had a few episodes of vomiting and diarrhea in the last 2 days Physical Exam:: Physical Exam : T 39°C, HR 170, RR 40 Well developed child; Drowsy, but arousable to tactile stimulation and voice Pale conjunctivae, Mucous membranes dry, TMs clear, Throat non-erythematous Unlabored breathing, Clear lung sounds; Tachycardic, no murmur Abdomen soft, mild splenomegaly Extremities warm, cap refill ~3 sec; No rash No neck stiffness, No focal neurologic deficits, moving all extremities Additional History: Additional History Previously healthy, no prior convulsions Immunizations up to date Family history: unremarkable, no history of epilepsy Fatima ’ s family lives in Ombokal village, 2-3 hours by car from the nearest hospital No sick contacts Anything else you would like to know? So before you freak out completely, you remember…: So before you freak out completely, you remember… Your alphabet!!! Airway, Breathing, Circulation, Coma & Convulsion ETAT manual- WHO Quickly you ask yourself a few questions…: Quickly you ask yourself a few questions… Is the child ’ s airway intact? Is she breathing? Can you feel her pulse? Does she have cold extremities or delayed capillary refill? Is she awake, alert? Is she seizing right now? Thankfully, she is no longer seizing, but what next?: Thankfully, she is no longer seizing, but what next? Position the patient And check the glucose If blood sugar less than 3 mmol/L or 55 mg/dL, give glucose Slide 10: On your assessment: Her blood sugar was normal But Fatima appears mildly dehydrated and febrile, so you administer an anti-pyretic suppository She is slowly waking up Encourage her to take PO fluids/breastfeed With a little more time, you now ask yourself, what could be the cause of the seizure?: With a little more time, you now ask yourself, what could be the cause of the seizure? Febrile convulsion due to an infection Meningitis, Encephalitis Cerebral malaria Hypoglycemia Hyponatremia Stroke (if sickle cell) Trauma Epilepsy Drug/Toxin Ingestion Tumors HIV infection Idiopathic Slide 12: One of our biggest concerns: Is it meningitis?! How do you distinguish between meningitis and a febrile convulsion? Is it a febrile convulsion or meningitis?: Is it a febrile convulsion or meningitis? Febrile convulsions Generally well appearing Normal mental state after short post- ictal period Short, generalized, non-recurring seizures only with fever Normal tone Meningitis Toxic/ill appearing Persistent altered mental state, lethargy/coma Reverse Irritability, neck stiffness Bulging fontanelle Seizures which are focal, prolonged, recurrent I ncreased tone or floppiness Sometimes subtle differences in babies, but look for level of alertness/responsiveness; muscle tone: Sometimes subtle differences in babies, but look for level of alertness/responsiveness; muscle tone Febrile viral illness Meningitis Increased tone; not responsive Normal tone; Tired, but responsive You check on Fatima again: You check on Fatima again She is now awake and crying… her mother is able to comfort her. Based on Fatima ’ s presentation and physical exam, does she have meningitis? No More likely, she has had a febrile convulsion Febrile Convulsion: Febrile Convulsion An event in neurologically healthy children between 6 mos and 6 yrs, associated with fever more than 38°C without evidence of intracranial infection or a defined cause and with no history of afebrile convulsions What kind of Febrile Convulsion? : What kind of Febrile Convulsion? Simple Generalized convulsions Duration <15 min Not recurring within 24 hrs No post-ictal neurologic abnormalities Complex (concern for meningitis) Focal Prolonged Recurrent within 24 hrs Associated with post-ictal neurologic abnormalities (Todd ’ s paralysis) Febrile status epilepticus Pathogenesis of Febrile Convulsions:: Pathogenesis of Febrile Convulsions: Direct cause unknown Thought to be an abnormal response by the hypothalamus which is still developing in young children Hypersensitive to changes in temperature Natural History & Prognosis: Natural History & Prognosis Incidence: 2-5% of all children (6mos-6yrs); peak incidence 18 mos Most common cause of convulsions in children Recurrence rates: 30-40% (half within the first 6 months of the first episode, ¾ within a year, 90% within 2 yrs) There is a slight increase in risk of developing epilepsy Simple febrile seizures ~1.5% increase Complex ~5% increase Study of febrile seizure etiology: Study of febrile seizure etiology 1350 children over a 8 year period (1998-2006) in Iraq, Jordan, and Yemen Irphan Shammari data So, how do we manage Fatima’s febrile seizure? Can we do it at your clinic?: So, how do we manage Fatima ’ s febrile seizure? Can we do it at your clinic? This is what you have : Basic exam room Glucometer Malaria testing A few antibiotics Diazepam rectal IV fluids & ORS Antipyretics You remember that there are protocols for you to follow…: You remember that there are protocols for you to follow… ETAT protocol (Emergency Triage Assessment and Treatment) developed by the WHO British Columbia Medical Services Commission guidelines & protocol Slide 23: BC Protocol Slide 24: BC Protocol According to the protocol, we can figure out what to do:: According to the protocol, we can figure out what to do: What focal signs does Fatima have? Conjunctival pallor, Cough, Splenomegaly Check for malaria as the most likely cause (in an endemic region) & treat if positive Observe at least 2 hours to make sure she can drink and appropriately come out of post- ictal phase But what if we have no focal signs? In our setting, we are unable to do further investigations…: But what if we have no focal signs? In our setting, we are unable to do further investigations… Should you refer? Fatima ’ s mother is worried she cannot pay for the transport to the hospital. Other children are at home… What do you do? In a perfect world, Conditions for Referral: In a perfect world, Conditions for Referral If unable to find source of illness & unwell Signs of meningismus, lethargy Recurrent convulsions, any complex convulsions Prolonged post-ictal period (> 2 hours), i.e. persistent altered mentation **BE SURE YOU GIVE ANTIBIOTICS TO COVER MENINGITIS BEFORE SENDING** In an imperfect world:: In an imperfect world: Plan A : If appears well, treat most likely cause based on physical exam Observe in clinic until able to drink Return in 1-2 days for a recheck Plan B : - If appears unwell and she can ’ t go to hospital, broad spectrum antibiotics to cover for meningitis - Repeat antipyretics and anti-epileptics as needed Supportive treatment: Supportive treatment Continued observation with antipyretics for comfort, undress, tepid sponging, cool liquids If recurrent seizures, give diazepam 0.5 mg/kg rectally or 0.25 mg/kg IV/IM or paraldehyde 0.3-0.4 mL/kg Repeat at same dose if seizure does not stop within 10 minutes **Remember to recheck blood sugar! (especially if treating with quinine) Do you need to refer later for follow-up investigations?: Do you need to refer later for follow-up investigations? LP (lumbar puncture)? According to AAP 2009 guidelines, not indicated unless: a) Signs of meningitis are present (neck stiffness, reverse irritability, bulging fontanel, signs of sepsis)- B b) Prior antibiotic/malarial treatment for this illness- D c) Unimmunized or partially immunized- D d) Meningitis season, endemic region* Slide 31: A study of 704 children 6-18 mos of age presenting with their first febrile seizure -98% fully immunized (includes pneumococcal and HiB) -271 (38%) had an LP attempted -CSF results recorded & Outcomes followed Slide 32: -10 of 260 samples had CSF pleocytosis (>7 cells /mm 3 ) -No pathogen identified in any culture -No patient returned to the hospital with a diagnosis of bacterial meningitis Do you need to refer later for follow-up investigations?: Do you need to refer later for follow-up investigations? Skull films? CT? Not indicated unless : a) H istory concerning for brain tumor (early morning vomiting, frequent falls, cranial nerve palsies) or b) S igns of stroke (unilateral weakness, focal deficits, cranial nerve palsies) or c) Recurrent complex febrile seizures- B Assessed by pros and cons:: Assessed by pros and cons : Pros Early detection of structural lesions such as dysplasia, tumor, abscess Parental relief Cons Exposure to radiation Potential need for sedation & risks associated with this No data have been published that either support or negate the need for CT or MRI Data support increased cancer risk with radiation exposure - Clinically important intracranial structural abnormalities in this patient population are uncommon Do you need to refer later for follow-up investigations?: Do you need to refer later for follow-up investigations ? EEG? Not indicated at all- B Has very low sensitivity in children under 3 years old Children with febrile convulsions often have epileptiform waves on EEG, but this is not an indication of further epilepsy Fatima’s blood films return…: Fatima ’ s blood films return… Positive for P. falciparum malaria She is able to drink her first dose of Artemisin combination meds and her fever is down Her mother wants to take her home but has a few more questions… “Does Fatima need seizure medicine?”: “ Does Fatima need seizure medicine? ” Intermittent? Continuous? Need to consider: a) Risks of not treating b) Risks to treatment Risks of Not Treating: Risks of Not Treating Potential concerns: 1) Decline in IQ 2) Death 3) Increased risk of epilepsy 4) Risk of recurrent febrile seizures Decreased IQ?: Decreased IQ? Slide 40: Study of outcomes of 103 children with febrile seizures, compared to a control population No significant differences found Risk of Death?: Risk of Death? Theoretical risk of death from a febrile seizure due to: Injury Aspiration Cardiac Arrhythmia Rare occurrences, no reports have been made to support this [AAP 2008] Increased Risk of Epilepsy?: Increased Risk of Epilepsy? By age 7, children with febrile seizures have the same risk (~1%) of developing epilepsy as the general population [NEJM 1976] If recurrent, occurring before 12 mos of age, or with a family history of epilepsy, there is an increased risk ~2.4% of later epilepsy [NEJM 1987] However , NO STUDIES have proven that treatment reduces this risk Recurrent Febrile Seizures?: Recurrent Febrile Seizures? Children with febrile seizures do have a high rate of recurrence If younger than 12 mos with first episode, 50% rate of recurrence If older, 30% rate of recurrence If a second seizure occurs, there is a 50% chance of at least 1 more recurrent seizure [ Arch Pediatr Adolesc Med. 1997] Should you give anti-epileptics to prevent recurrent seizures?: Should you give anti-epileptics to prevent recurrent seizures? No substantial morbidity and no mortality associated with febrile seizures Parental anxiety (Relief with treatment vs. Anxiety about administering drug) Significant side effects from treatment Fatal hepatoxicity Thrombocytopenia Weight loss/gain & GI disturbances Hyperactivity, irritability, lethargy, sleep disturbances, ataxia Respiratory depression Slide 45: BMJ The verdict:: The verdict : Intermittent therapy Diazepam study: Reduced seizures if given at time of fever 22-44% N on-compliance due to side effects Therapy does reduce the number of recurrent seizures, but outcome studies show no difference [Knudsen 1996] E vidence shows that harm outweighs potential benefit The verdict:: The verdict: Continuous therapy Phenobarbital study: reduced rate of seizures from 25 per 100 children to 5 per 100 per year Required daily therapy to reach consistent blood levels Side effects severe enough to cause up to 40% to stop therapy Therapy does reduce the number of recurrent seizures E vidence shows that harm outweighs benefit “Does she need antipyretics?”: Data have not shown any decrease in frequency of recurrence with antipyretics [AAP 2008] Multiple studies show no reduction in seizures with the use of either acetaminophen or ibuprofen Camfield 1980, Schnaiderman 1993, Uhari 1995 MAY play a role in treating pain and improving child discomfort “ Does she need antipyretics? ” Conclusions:: Conclusions: Can we manage a child with febrile convulsions in our rural clinic? Yes! We use a modified protocol and treat the most likely cause according to focal signs If any concern for meningitis, start antibiotics right away (even if unable to confirm or refer) Education of the mother on supportive care and follow-up is KEY Emphasize the need for return if seizures recur or if any deterioration in condition Questions?: Questions?