SNIPPETS
Seven Practice Points on Febrile Seizures
- Complex febrile seizure can be either focal, duration more than 15 min, or multiple episodes in 24 hours.
- Simple febrile seizure plus(SFS+) are febrile seizures that are generalized, last for less than 15 min, but have more than one episode in 24 hours. SFS+ behaves like SFS rather than CFS and the overall prognosis is same as SFS.
- There are only three indications for lumbar puncture: (a) Presence of Meningeal signs, (b) Infant 6-12 months when not vaccinated for Hib/Pneumococcal or when the immunization status is not known, and (c) optional indication if the child has been pretreated with antibiotic.
- There is no role of EEG or MRI Brain in simple febrile seizure. Role is restricted to focal febrile seizure and febrile status epilepticus or when there is pre-existing developmental delay.
- The use of antipyretic agents does not alter the recurrence rate (class 1 evidence), and there is no evidence to support initiation of regular antiepileptic drugs for simple febrile seizures (class 1 evidence)
- Intermittent prophylaxis with clobazam is prescribed only when there are more than three seizures in 6 months, or more than four seizures in 12 months, seizures last for more than 15 minutes, or in the seizures that require medication.
- Continuous prophylaxis with sodium valproate is indicated among children with febrile status epilepticus (prolonged febrile seizure beyond 30 minutes), complex and recurrent FS >6 yr despite intermittent prophylaxis..
References
1. Mastrangelo M, Midulla F, Moretti C. Actual insights into the clinical management of febrile seizures. Eur J Pediatr. 2014;173:977–82.
2. Lewis DV, Shinnar S, Hesdorffer DC, Bagiella E, Bello JA, Chan S, et al. Hippocampal sclerosis after febrile status epilepticus: the FEBSTAT study. Ann Neurol. 2014;75:178–85.
3. Subcommittee on Febrile Seizures, American Academy of Pediatrics. Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics. 2011;127:389–94.
4. Grill MF, Ng Y-T.. “Simple febrile seizures plus (SFS+)”: more than one febrile seizure within 24 hours is usually okay. Epilepsy Behav EB. 2013;27:472–6.
5. Wilmshurst JM, Gaillard WD, Vinayan KP, Tsuchida TN, Plouin P, Van Bogaert P, et al. Summary of recommendations for the management of infantile seizures: Task Force Report for the ILAE Commission of Pediatrics. Epilepsia. 2015;56:1185–97. Visit to read https://onlinelibrary.wiley.com/doi/epdf/10.1111/epi.13057
AAP guidelines on Fruit consumption in children
1. Juice should not be introduced into the diet of infants before 12 months of age unless clinically indicated.
2. Toddlers should not be given juice from bottles, easily transportable covered cups or at bedtime.
3. The intake of juice should be limited to, at most, 4 ounces/day in toddlers 1 through 3 years of age, and 4 to 6 ounces/day for children 4 through 6 years of age.
4. For children 7 to 18 years of age, juice intake should be limited to 8 ounces or 1 cup of the recommended 2 to 2.5 cups of fruit servings per day.
5. The committee advocates and encourages use of fruits as compared to juices to meet the daily requirements and energy balance.
6. Maximum 50% of fruits can be provided as fruit juice (not fruit drink)
7. Grapefruit juice should be avoided in any child taking medication that is metabolized by CYP3A4
8. In the evaluation of children with malnutrition, dental caries and malnutrition, the pediatrician should determine the amount of juice being consumed.
9. Pediatricians should advocate for a reduction in fruit juice in the diets of young children and the elimination of fruit juice in children with abnormal (poor or excessive) weight gain.
10. Pediatricians should promote the consumption of whole fruit by toddlers and young children.
To read the full text, visit: http://pediatrics.aappublications.org/content/139/6/e20170967
The International Society for Pediatric and Adolescent Diabetes (ISPAD) new guidelines on management of Diabetes In children
Diabetes affects almost 1.1 million children globally. The International Society for Pediatric and Adolescent Diabetes (ISPAD) released new guidelines on management of Diabetes for children. Below are few highlights of the guidelines:
1. Type 1 diabetes is essentially a clinical diagnosis. A finger prick glucose value or single plasma glucose value without clinical features should not be taken for confirmatory diagnosis.
2. Aim for HbA1C target of <7% on insulin therapy.
3. Target glycemic goals: before meals: 70-130 mg/dL; overnight: 80-140 mg/dL.
4. Measure TSH, antithyroid peroxidase and antithyroglobulin, antiTTG, with serum IgA levels soon after diagnosis.
5. Obtain lipid profile in children >11 years of age.
6. Recheck TSH every 1-2 years. Repeat screening for celiac within 2 years and 5 years of diagnosis.
7. Blood pressure to be measured at each visit. Blood pressure cut off of >95th centile to be labelled hypertension if measured on three occasions.
8. Annual screening for albuminuria, retinopathy and peripheral neuropathy to be performed at age >11 years with disease duration of 2-5 years whichever is earlier.
9. Recognition of type 2 diabetes among childhood and adolescence is important.
10. Insulin therapy with a combination of rapid/ short acting and long acting insulin to be preferred. Premixed insulins should not be used.
To read the full text, please visit https://www.ispad.org/page/ISPADGuidelines2018
AAP Clinical Practice Guideline for Management of High Blood Pressure in Children
Few major points from AAP Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents:
Hypertension is now classified as follows:
| Definition | 1-13 years | >13 years |
| Normal BP | <90th centile | <120/<80mmHg |
| Elevated BP | >90th to <95th centile | 120/<80 to 129/<80mmHg |
| Stage 1 hypertension | ≥95th centile to <95th centile +12 mmHg or >130/80 to 139/89 mmHg | 130/80 to 139/89mmHg |
| Stage 2 hypertension | ≥95th centile + 12 mmHg or ≥140/90mmHg (whichever is lower) | ≥ 140/90mmHg |
BP should be measured annually in children and adolescents ≥3 y of age.
- BP should be checked in all children and adolescents ≥3 y of age at every health care encounter if they have obesity, are taking medications known to increase BP, have renal disease, a history of aortic arch obstruction or coarctation, or diabetes.
- Echocardiography to be performed to assess for cardiac target organ damage (LV mass, geometry, and function) at the time of consideration of pharmacologic treatment of HTN.
- The role of lifestyle modifications (DASH diet, physical activity etc) in hypertension management has been emphasized.
- Clinicians should initiate pharmacologic treatment with an ACE inhibitor, ARB, long-acting calcium channel blocker, or thiazide diuretic after failed lifestyle modifications.
- Goal of therapy is to maintain SBP and DBP < 90th centile or 130/80 mmHg whichever is lower. In children at risk like CKD the target BP should be <50 th centile.
New ILAE operational classification of seizure types, 2017
1. As per the recent International league against epilepsy (ILAE) classification, partial seizures are now called as focal seizures.
2. The terms like simple partial seizure and complex partial seizure are no longer used. We use focal seizure with preserved awareness or focal seizure with impaired awareness.
3. Seizures can be focal, generalized, unknown onset, or unclassified onset.
4. We call it unclassified when the seizure was not witnessed or it is not clear whether the onset was focal or not.
5. New seizure types that are now included in the ILAE classification include absence with eyelid myoclonia, myoclonic atonic, behavioural arrest, and emotional.
6. Seizures types that are not used anymore include dyscognitive or psychic seizures type.
7. Focal seizures often respond well to carbamazepine, oxcarbazepine, phenytoin and levetiracetam.
8. Generalized seizures respond well to sodium valproate, levetiracetam.
9. Avoid valproate in adolescent girl (risk of obesity and PCOS), avoid levetiracetam in those with pre-existing behavioural disturbances, avoid phenytoin in adolescent girls (cosmetic reason), avoid phenytoin or carbamazepine for chronic prophylaxis of focal febrile seizure or febrile status epilepticus.
(Compiled by: Dr Piyush Gupta, Professor of Pediatrics and In-charge, Medical Education Unit, University College of Medical Sciences, Delhi.)