Acute Seizures In Children Research Articles

Intranasal vs Buccal vs Intramuscular Midazolam for the Home and Emergency Treatment of Acute Seizures in Pediatric Egyptian Patients

Abstract Introduction: Acute convulsions in children are a common emergency worldwide. Benzodiazepines are the recommended first line of treatment. We wished to compare the efficacy, ease of administration and overall satisfaction of midazolam by the buccal, intranasal orintramuscular route in the treatment of acute seizures in Egyptian children both at homes and Emergency room (ER) Methods A prospective, randomized, trial was performed in children aged 1 months to 17 years with acute seizures lasting longer than 5 min. Children were randomly assigned to receive midazolam, 0.2 mg/kg, by the buccal, intranasal or intramuscular route. The primary endpoint was seizure cessation within 10 min of drug administration and no seizure recurrence within 30 minutes. Results There were 196 seizures analysed in home group, 67 patients received midazolam via buccal route, 60 via intranasal, 69 via intramuscular route while 105 patients were recruited from ER 37 patients received buccal midazolam, 34 received intranasal and 34 received intramuscular midazolam. Intramuscular midazolam stopped seizures within 10 min in 94.2 % in home group and 85.3 % in ER group. On the other hand, intranasal midazolam was successful to stop seizures in 93.3% in home group and 88.2 % in ER group within 10 minutes. The buccal route was effective in 91% in home group and 78.4 % in ER group. There were no significant differences in efficacy between all groups. P = 0.763 and P = 0.509 among home and ER groups respectively. Time to seizure cessation was significantly higher in the buccal group 5.11 ± 1.23minutes in home group and 5.91 ± 1.25 in ER group (P = 0.000). Highest overall satisfaction and ease of administration was seen in intranasal group especially among caretakers in home group > 7= 49 (81.7 %) P = 0.002.. Intramuscular midazolam was more preferred by physicians in ERgroup >7=32 (94.1%) (P = 0.001) There were no significant cardio-respiratory events in all groups. Conclusions Our results indicate that there is no clinically important difference between buccal, intranasal and IM routes of administration midazolam. Buccal and intranasal midazolam were safe and effective for treatment of acute seizures in children.

Intranasal Versus Buccal Versus Intramuscular Midazolam for the Home and Emergency Treatment of Acute Seizures in Pediatric Patients: A Randomized Controlled Trial

BackgroundBenzodiazepines are the recommended first-line treatment of acute seizures. We wished to compare the efficacy, side effects, and satisfaction after midazolam administration by the buccal, intranasal, or intramuscular route in the treatment of acute seizures in children at homes and in emergency room (ER). MethodsA prospective, randomized, controlled trial was performed in children aged one month to 17 years with acute seizures lasting longer than five minutes. The primary end point was seizure cessation within 10 minutes of drug administration and no seizure recurrence within 30 minutes. ResultsIn the home group, 67 patients received midazolam via buccal route, 60 via intranasal route, and 69 via intramuscular route, whereas in the ER group, 37 patients received buccal, 34 received intranasal, and 34 received intramuscular midazolam. The primary end point was achieved in 94.2% and 85.3% after intramuscular midazolam in the home and ER groups, respectively. The intranasal midazolam was successful in stopping seizures in 93.3% in the home group and 88.2% in the ER group. The buccal route was effective in 91% in the home group and 78.4% in the ER group. There were no significant differences in efficacy between all groups (P = 0.763 and P = 0.509) among the home and ER groups, respectively. There were no significant cardiorespiratory events in all groups. ConclusionsIntramuscular, intranasal, and buccal doses of midazolam resolved most seizures in prehospital and emergency settings. Our results indicate that there is no statistically significant difference detected between different routes of midazolam. Intranasal route showed the highest satisfaction rate among caregivers.

Midazolam nasal spray to treat intermittent, stereotypic episodes of frequent seizure activity: pharmacology and clinical role, a comprehensive review.

An intranasal formulation of midazolam, Nayzilam, has been FDA-approved to treat intermittent, stereotypic episodes of frequent seizure activity. Nayzilam is easy to administer and can quickly treat seizures that occur outside of the hospital. The intra-nasal route of administration allows non-medical personal to administer the drug which makes it more accessible and user-friendly in the event of a seizure. Many studies have indicated quick cessation of seizures with Nayzilam compared to rectal diazepam, which has been the standard of care treatment. Nayzilam has been proven to be safe and effective for acute seizures in children, deeming it a revolutionary alternative in times where intravenous administration is not possible.

Intra Nasal Midazolam vs. Rectal Diazepam in Management of Acute Seizures in Pediatrics, Considering the Antiepileptic Drugs Monitoring

Immediate management of children's epilepsy is essential before the patient arrives to the hospital. The purpose of this study was to compare the efficacy of intranasal midazolam vs. rectal diazepam in the management of acute pediatric seizures. In this cross-sectional study, 68 patients having acute seizure were evaluated for response to treatment after receiving intra-nasal midazolam (34 patients) or rectal diazepam (34 patients). Patents were assessed by physicians at the arrival to emergency department for history taking and examination. Blood samples were assessed for valproate, phenobarbital and phenytoin levels in serum to determine previous use of antiepileptic drugs. Seizure duration and response time to treatment were evaluated along with health care utilization and were compared between study groups, by the statistical package for the social sciences software. Mean age of study participants, sex disturbance, age at onset of a seizure, type of seizure and prehospital time had not any significant differences between two groups (p>0.05). The mean response time to diazepam was 8.0±4.9 min and 6.3±2.2 min for midazolam; which had a significant difference between groups (0.001). Linear regression of serum antiepileptic drug levels in association of response time in each group was not significant in all case (p>0.05), expect the lamotrigine serum level in midazolam group (p=0.029). Intranasal midazolam was seen to have a better effect than rectal diazepam in the management and treatment of acute seizures in children; while antiepileptic drugs monitoring want helpful in assessing the absolute effect.

Management of Epilepsy among Children in the Gaza Strip: A Multicenter Clinical Audit

Introduction: Seizures are scary phenomena but are quite common especially among children: about 8% will have had at least one seizure by 15 years of age. Most acute seizures in children are brief, terminating spontaneously and do not need any treatment. Seizures that persist beyond 5 min may not stop spontaneously and necessitate comprehensive clinical evaluation and medical care. Seizure control then becomes a matter of urgency for the patient and his family, as the longer the duration of the seizure, the greater the bad effects on body systems especially the brain and the more difficult control is likely to become. Methods: A retrospective, multicenter clinical audit was undertaken simultaneously at the three largest centers for epilepsy management in Gaza. A total of 190 medical records were included in our audit from January 1, 2017, to April 30, 2018. Aims and Objectives: Our audit aims to evaluate the care provided for patients with epilepsy from diagnosis to treatment and follow-up and to compare it against the latest National Institute for Health and Care Excellence (2017) guidelines and AACC (American Association for Clinical Chemistry) (January 7, 2018). Results: Among 190 reviewed medical records, 61% patients were males and the median age was 9 ranging from 6 to 13 years. 31.5% (n = 60) of cases suffered from various comorbidities. The overall adherence of health care professionals to audit standards was moderate. There was severe dearth of information in the medical records. Most records (n = 147, 77.4%) did not include the seizure type, frequency, and duration. Drug therapy was inconsistent with seizure type in 16 cases (8.4%). Investigations were underutilized generally. There were marked differences in the practice among health care centers. Conclusion: The vast majority of files (n = 138, 72.6%) suffered from poor documentation of seizure type, frequency, and duration which needs to be improved. Drug prescription was inconsistent and highly variable and dependent on the treating doctor’s memory and diligence. Moreover, electroencephalogram, electrocardiogram, and drug level testing were highly suboptimal. Health professionals should modify and adopt the AACC recommendations to improve diagnostic and therapeutic service and reduce potential complications and sufferings of epileptic patients.

Comparing the effectiveness of intranasal Midazolam and intravenous Lorazepam for the treatment of acute seizures in children

Objective: The objective of this study was to compare the safety and efficacy of intranasal midazolam with intravenous lorazepam in acute seizures in children. Methods: Children aged 6 months–12 years with active tonic/clonic/tonic-clonic seizures coming to the pediatric emergency department were enrolled in the study after getting informed consent. Groups were randomly distributed (Group 1: Intranasal midazolam; Group 2: IV lorazepam) and the sample size was 80 (40 in each group). Under clinical and pulse oximetry monitoring, aqueous midazolam 0.2 mg/kg was administered intranasally through automated aqueous intranasal spray(Midacip 0.5mg per puff) in lying down or in 45° propped up position to Group 1, while injectable lorazepam 0.1 mg/kg was administered intravenously slow (to a maximum of 4 mg) to Group 2. Results: Both the groups were found to be comparable in baseline characteristics. Mean time to administer the drug after arrival to the doctor in intranasal midazolam and IV lorazepam was 3.65 (standard deviation [SD] 1.167) min and 7.93 (SD 3.23) min, respectively (p=0.0001). Intranasal midazolam group had significant control of seizures in <5 min of arrival (p=0.0006). The control of seizures within 1 min after drug administration was also found to be more effective in midazolam group (p=0.004). No adverse effects or respiratory depression were found in any of the groups. Conclusion: The ease to administer, effectiveness, and rapid onset of action of intranasal midazolam without causing any respiratory depression enable it to be considered as a first-line drug for acute seizures in all settings including homes/day-care centers.

Providing teachers with education on epilepsy increased their willingness to handle acute seizures in children from one to 10 years of age.

In Germany, preschool teachers supervise children up to six years of age and are also responsible for supervising older pupils after school. This study explored the impact of a teaching session on epilepsy for teachers in charge of children from 1 to 10 years of age. We evaluated the benefit of a teaching session offered to all preschool teachers in Leipzig, Germany, in 2014-2015, by asking them to complete the same questionnaire 12-24 months pre-intervention, and 12 months postintervention. Both questionnaires were completed by 123 teachers. The number of teachers who felt they were prepared to handle an acute seizure rose from 36 (29%) pre-intervention to 65 (53%) post-intervention (p < 0.001) and their willingness to administer a prescribed rescue medication rose from 66 (54%) to 93 (76%, p < 0.001). The session also increased the number of teachers who were prepared to take children with epilepsy on excursions under any circumstance from 38 (31%) to 52 (42%, p < 0.05). In addition, the number of teachers who would place a solid object in the child's mouth during an attack fell from 16 (13%) to seven (6%) (p < 0.05). Providing a teaching session on epilepsy increased the teachers' knowledge and willingness to act and reduced obsolete, counterproductive measures.

Management of acute seizures in children: A review with special consideration of care in resource-limited settings.

IntroductionWe sought to review recent evidence-based guidelines and where applicable, primary data to extrapolate insights into the appropriate management of acute seizures in children in resource-limited settings.MethodsPubMed and Google scholar searches were conducted with attention to publications from the last three to five years, including a focused search for acute seizure management guidelines relevant to resource limited settings. Since all guidelines to date, except the World Health Organization’s, assume ready access to invasive ventilation and advanced diagnostic testing, guidelines and primary data were used to propose management appropriate for resource-limited settings where respiratory suppression from treatment presents a major challenge in management.ResultsAcute seizures are among the commonest medical emergencies encountered in the African settings. Seizure management must occur simultaneously with the diagnostic assessment, which should include addressing life threatening causes (e.g. hypoglycaemia, malaria) and with attention given to the most likely aetiology in a particular region or setting. For ongoing seizures, initial treatment with benzodiazepines is indicated. There is evidence of efficacy for several agents and delivery modes. Longer-acting antiepileptic drugs (AEDs) should be on hand if acute seizures fail to respond to two doses of benzodiazepines. There is little direct evidence comparing the relative efficacy of different long-acting AEDs for acute seizure management in African children. Findings suggest that generalising data from Western settings, where different aetiologies and risk factors for seizures prevail, may be inappropriate.DiscussionThough treatment options and diagnostics may be dictated by available medications and capacity, it is possible for virtually any healthcare setting to develop a relevant and feasible local guideline for seizure management. Clear specifications on when to refer to a higher level of care should be part of the care plan.

Risk of convulsive epilepsy following acute seizures in Kenyan children.

SummaryObjectiveThe prevalence of epilepsy is high in Africa, and people with epilepsy often have a history of acute seizures. We determined whether acute seizures are associated with risk for epilepsy in rural Africa, where both conditions are common and may have shared risk factors.MethodsA total of 16,438 children (2,991 with acute seizures and 13,447 without seizures) admitted to Kilifi County Hospital from 2002 to 2008 were followed up with epidemiological surveys conducted in 2003 and 2008 to assess the prevalence of epilepsy and the associated risk factors. Cox proportional hazards regression models were used to identify the risk factors. Prevalence ratios were computed using log binomial regression models.ResultsThe prevalence of epilepsy was higher in admissions with acute seizures (5.0% [95% confidence interval (CI), 4.3–5.9%]) than in those without seizures (0.7% [95% CI, 0.5–0.8%]), p < 0.0001). Acute seizures were associated with epilepsy after accounting for potential confounders in a Cox regression model (hazard ratio [HR] = 1.53 [95% CI, 1.10–2.14]). Prevalence was greater in complex acute seizures (5.9%; prevalence ratio [PR] = 1.58 [95% CI, 1.13–2.20]) or status epilepticus (7.5%; PR = 1.96 [95% CI, 1.32–2.91]) than in simple acute seizures (3.7%). Factors independently associated with epilepsy following acute seizures in Cox regression models were perinatal complications (HR = 3.60 [95% CI, 1.89–6.87]), cerebral palsy (HR = 1491.51 [95% CI, 144.30–15,416.21]), duration of follow‐up (HR = 1.21 [95% CI, 1.09–1.35]), and malnutrition (relative risk [RR] = 0.24 [95% CI, 0.08–0.69]).SignificanceAcute seizures in children are associated with subsequent risk for epilepsy that is greater than in the general population. The burden of epilepsy may be reduced by control of causes of acute seizures.

ABSTRACT 821

Background and aims: Seizure is a common reason for hospital visits of children. However, little is known about the causes and management of acute seizures in children from the developing countries. Aims: The aims of this study was to identify the etiologies of seizure and appropriateness of initial treatment for acute seizures in children presenting at the Emergency Department of a tertiary hospital in Vietnam. Methods: This descriptive study was conducted at the Emergency Department of the National Hospital of Pediatrics, Hanoi, Vietnam during a period of January 2013 to June 2013. Demographic data, clinical manifestation, laboratory investigations, neuro-imaging results, the appropriateness of treatment, and outcome of seizure were collected from medical records. The study has had IRB’s approval from the hospital. Results: Of the 452 patients were admitted for seizures, 283 (62.6%) were males and 90.0% of these children were less than 5 years old. Generalized tonic-clonic seizures were the most common seizure type (84.7%) and majority (92.0%) of seizure episodes were less than 5 minutes. Febrile seizures (49.8%), epileptic disorders (30.8%), and central nervous system (CNS) infections (13.5%) were the most common etiologies. Abnormal brain images was noted in 31/152 patients (20.4%). Intravenous midazolam was the common medication for first-line treatment (88.2%), and 82.7% of seizure episodes were terminated after first-line treatment. A total of 31 patients developed recurrent seizures. Conclusions: Febrile convulsions, epileptic disorders, and CNS infections were common causes of seizures in children. Brain imaging should be considered for afebrile seizure episodes. Intravenous loading midazolam was effective first-line treatment for acute seizures.

Acute symptomatic seizures as a complication of rhinosinusitis in children

When an otorhinolaryngologist thinks of acute seizures in children, what comes to mind are intracranial complications of infection within the sinuses or the temporal bone. Complications of rhinosinusitis, both in children and adults, may involve the orbit, soft tissues surrounding the nose and sinuses, and intracranial spread of the infection. Intracranial complications secondary to rhinosinusitis, intracranial abscesses and/or thrombophlebitis, occur sporadically and, although it appears that they cannot be prevented, early recognition and treatment are essential to reduce any subsequent morbidity or mortality [1]. The commonest presenting symptoms of intracranial complications are headaches (80%) followed by vomiting (45%) and swelling of the forehead (45%), an altered mental state, fever, seizure, unilateral weakness or hemiparesis, or a cranial nerve sign [1,2]. Exact pathogenesis of intracranial abscesses remains unclear [3]. Apart from rhinosinusitis, congenital cyanotic heart disease was identified as a predisposing factor, likewise otitis media or mastoiditis, dental abscesses and immunodeficiency [3]. The diagnosis of cerebral abscess is often difficult. The classical intracranial hypertension associated to high fever is usually incomplete and sometimes absent [4]. In most cases (60%), it is from the frontal sinus that the infection spreads intracranially [2]. In patients with intracranial complications of rhinosinusitis, frequency of seizures reaches 10–25% [1,3,5]. Epilepsy caused by intracranial complications is usually a long-term morbidity [1]. Above enumerated presenting symptoms justify an urgent magnetic resonance imaging (MRI) or computed tomography (CT) scan. The importance of imaging before a lumbar puncture cannot be overemphasized [1,6]. Since the availability of CT, both diagnostic delay after hospital admission and mortality were substantially reduced: mean delay from 8 to 3 days, andmortality from 25% to almost 0% [3]. In patients with intracranial complications, acute symptomatic seizures are usually accompanied by other neurological symptoms: fever in 50% of cases, headache in 75% of cases, and intracranial hypertension syndrome in 25% of cases [4]. The condition requires sinus surgery in order to drain the primary focus of the infection [2,7]. At the same time, prompt and aggressive medical and neurosurgical intervention is required, aiming tominimize the morbidity and mortality and to maximize the favorable outcome in those children [2]. The neurosurgical procedures aim to drain the abscess and include burr whole drainage or aspiration of abscess, craniotomy and evacuation of empyema, or craniotomy [2]. Central nervous system scars with subsequent seizures can be sequels of intracranial abscess therapy and are more common after excision of the brain abscess when compared to patients treated by aspiration and/or antibiotics alone [2,3,7]. Therefore, excision of brain abscess should be avoided *Address for correspondence: Olaf Zagolski, ENT, St. John Grande’s Hospital, Krakow, Poland. Tel.: +48 12 3797377; Fax: +48 12 4305491; E-mail: olafzag@poczta.onet.pl. Journal of Pediatric Epilepsy 1 (2012) 73–74 DOI 10.3233/PEP-2012-012 IOS Press 73

Rectal Diazepam Solution Is as Good as Rectal Administration of Intravenous Diazepam in the First-aid Cessation of Seizures in Children With Intractable Epilepsy

Acute seizures are readily recognizable episodes requiring urgent treatment. This study was conducted to compare the efficacy and safety of suppository use of rectal diazepam solution [Stesolid rectal tube (SRT), Alpharma, Inc., Lierskogen, Norway] with those of intravenous diazepam (IVD), Li Ta Pharma Co, Ltd., Taichung, Taiwan for control of acute seizures in children with intractable epilepsy. Subjects were patients, aged 1-18 years, with intractable epilepsy under at least three kinds of antiepileptic treatments. Caregivers were trained to rectally administer SRT or IVD (dosage varying from 0.2 to 0.5mg per kilogram of body weight) and to monitor respiration condition, seizure severity, and adverse drug effects. Among the 24 subjects, 9 males and 15 females, treated for a period of 3 months, the ages ranged from 2 to 18 years, with a mean of 9.1 years. Seizure types were generalized tonic and/or clonic. Seizure frequency varied from once per week to 20 times per day. Twenty-one (87.5%) of them had mental retardation and/or developmental delay, and 103 of the 127 (81.1%) IVD administrations and 90 of the 103 (87.3%) SRT administrations resulted in rapid cessation of seizures within 10 minutes. Each first dose failed to control seizures in 24 and 13 episodes, respectively. A second dose of IVD achieved cessation of seizure in 21 of the 24 episodes and a second dose of SRT in 12 of the 13 episodes within another 10 minutes. Four episodes (3 with rectal IVD and 1 with SRT) of prolonged seizure beyond 20 minutes needed IVD injection at our emergency room. Sedation occurred in 17% of patients, which was attributed to IVD in 8% and SRT in 9% of patients. No respiratory depression was attributable to IVD or SRT. There was no significant statistical difference in efficacy and safety between these two forms of diazepam. Rectal diazepam solution, administered by capable caregivers, is as effective and safe as rectal administration of IVD for children with intractable epilepsy.

Intranasal versus intravenous lorazepam for control of acute seizures in children: A randomized open‐label study

Intravenous lorazepam is considered the drug of first choice for control of acute convulsive seizures. However, resource or personnel constraints necessitate the study of alternative routes and medications. This study compared the efficacy and adverse effects of intranasal versus intravenous lorazepam in children aged 6-14 years who presented with acute seizures. This was a randomized open-label study conducted at an Indian hospital from August 2008 to April 2009. One hundred forty-one consecutive children aged 6-14 years who presented convulsing to the emergency room were included. After stabilization, the children were randomized to receive either intravenous or intranasal lorazepam (0.1 mg/kg, maximum 4 mg). The primary outcome measure was clinical seizure remission within 10 min of drug administration. The study was registered with clinicaltrials.gov (NCT00735527). Seventy patients were randomized to receive intravenous and 71 to receive intranasal lorazepam. The patients in the two groups were comparable at baseline. Clinical seizure remission within 10 min of drug administration was found in 80% of the intravenous group as compared to 83.1% of intranasal group. The lower limit of 95% confidence interval for effect size was approximately -9.7%, with an a priori cutoff for noninferiority of -10%. Intranasal administration of lorazepam is not found to be inferior to intravenous administration for termination of acute convulsive seizures in children.

Iron Deficiency and Acute Seizures: Results from Children Living in Rural Kenya and a Meta-Analysis

BackgroundThere are conflicting reports on whether iron deficiency changes susceptibility to seizures. We examined the hypothesis that iron deficiency is associated with an increased risk of acute seizures in children in a malaria endemic area.MethodsWe recruited 133 children, aged 3–156 months, who presented to a district hospital on the Kenyan coast with acute seizures and frequency-matched these to children of similar ages but without seizures. We defined iron deficiency according to the presence of malarial infection and evidence of inflammation. In patients with malaria, we defined iron deficiency as plasma ferritin<30µg/ml if plasma C-reactive protein (CRP) was<50mg/ml or ferritin<273µg/ml if CRP≥50mg/ml, and in those without malaria, as ferritin<12µg/ml if CRP<10mg/ml or ferritin<30µg/ml if CRP≥10mg/ml. In addition, we performed a meta-analysis of case-control studies published in English between January 1966 and December 2009 and available through PUBMED that have examined the relationship between iron deficiency and febrile seizures in children.ResultsIn our Kenyan case control study, cases and controls were similar, except more cases reported past seizures. Malaria was associated with two-thirds of all seizures. Eighty one (30.5%) children had iron deficiency. Iron deficiency was neither associated with an increased risk of acute seizures (45/133[33.8%] cases were iron deficient compared to 36/133[27.1%] controls, p = 0.230) nor status epilepticus and it did not affect seizure semiology. Similar results were obtained when children with malaria, known to cause acute symptomatic seizures in addition to febrile seizures were excluded. However, in a meta-analysis that combined all eight case-control studies that have examined the association between iron deficiency and acute/febrile seizures to-date, iron deficiency, described in 310/1,018(30.5%) cases and in 230/1,049(21.9%) controls, was associated with a significantly increased risk of seizures, weighted OR 1.79(95%CI 1.03–3.09).ConclusionsIron deficiency is not associated with an increased risk of all acute seizures in children but of febrile seizures. Further studies should examine mechanisms involved and the implications for public health.

Intravenous Levetiracetam in the Management of Acute Seizures in Children

Levetiracetam may be effective in children with acute seizures or status epilepticus. We performed a retrospective chart review of children who received intravenous levetiracetam within 30 minutes of a seizure. Seventy-three patients during a 2-year study period met our inclusion criteria. The mean (+/- S.D.) age and weight of the patients were 5.59 +/- 5.6 years (range, 1 day to 17.8 years) and 23.1 +/- 21 kg (range, 1.97-97 kg), respectively. Patients received a mean (+/- S.D.) levetiracetam dose of 29.4 +/- 13.5 mg/kg. Most children (n = 49, or 67%) received additional antiepileptic drugs to abort their seizure. Overall, the mean (+/- S.D.) total (abortive plus chronic) number of concomitant antiepileptic drugs used by the population was 2.53 +/- 1.7 (1.07 +/- 0.98 as additional abortive therapy, and 1.42 +/- 1.29 as chronic therapy). Most patients received levetiracetam for serial seizures (79%), whereas 12% and 8% manifested a single seizure or status epilepticus, respectively. Clinical effectiveness at 1, 12, 24, 48, and 72 hours after the initial levetiracetam dose constituted the primary study outcome. Eighty-nine percent of patients remained seizure-free at 1 hour. This rate decreased at each evaluation time point. Most patients (71%) were placed on maintenance levetiracetam within 24 hours of their loading dose. The predictive ability of patient and drug regimen variables in outcomes was poor. Only the number of concomitant antiepileptic drugs consistently predicted outcomes. Levetiracetam was well tolerated at the doses studied, and appears most effective in single seizure events.

PO18-WE-40 Buccal midazolam compared to rectal diazepam and intravenous midazolam as emergent treatment of acute seizures in children: preliminary study

PO18-WE-40 Buccal midazolam compared to rectal diazepam and intravenous midazolam as emergent treatment of acute seizures in children: preliminary study

Haptoglobin HP2-2 genotype, α-thalassaemia and acute seizures in children living in a malaria-endemic area

SummaryPolymorphisms of the haptoglobin (HP) gene and deletions in α-globin gene (α-thalassaemia) are common in malaria-endemic Africa. The same region also has high incidence rates for childhood acute seizures. The haptoglobin HP2-2 genotype has been associated with idiopathic generalized epilepsies and altered iron metabolism in children with α-thalassaemia can potentially interfere with neurotransmission and increase the risk of seizures. We investigated the hypothesis that the HP2-2 genotype and the common African α-globin gene deletions are associated with the increased risk of seizures. 288 children aged 3–156 months admitted with acute seizures to Kilifi District Hospital (Kenya), were matched for ethnicity to an equal number of community controls. The proportion of cases (72/288 [25.0%]) and controls (80/288 [27.8%]) with HP2-2 genotype was similar, p = 0.499. The allele frequency of HP2 gene in cases (49.3%) and controls (48.6%) was also similar, p = 0.814. Similarly, we found no significant difference between the proportion of cases (177/267 [66.3%]) and controls (186/267 [69.7%]) with deletions in α-globin gene (p = 0.403). Among cases, HP2-2 polymorphism and deletions in α-globin gene were neither associated with changes in the type, number or duration of seizures nor did they affect outcome. We conclude that the HP2-2 polymorphism and deletions in α-globin gene are not risk factors for acute seizures in children. Future studies should examine other susceptibility genes.

The incidence, aetiology and outcome of acute seizures in children admitted to a rural Kenyan district hospital

BackgroundAcute seizures are a common cause of paediatric admissions to hospitals in resource poor countries and a risk factor for neurological and cognitive impairment and epilepsy. We determined the incidence, aetiological factors and the immediate outcome of seizures in a rural malaria endemic area in coastal Kenya.MethodsWe recruited all children with and without seizures, aged 0–13 years and admitted to Kilifi District hospital over 2 years from 1st December 2004 to 30th November 2006. Only incident admissions from a defined area were included. Patients with epilepsy were excluded. The population denominator, the number of children in the community on 30th November 2005 (study midpoint), was modelled from a census data.ResultsSeizures were reported in 900/4,921(18.3%) incident admissions and at least 98 had status epilepticus. The incidence of acute seizures in children 0–13 years was 425 (95%CI 386, 466) per 100,000/year and was 879 (95%CI 795, 968) per 100,000/year in children <5 years. This incidence data may however be an underestimate of the true incidence in the community. Over 80% of the seizures were associated with infections. Neonatal infections (28/43 [65.1%]) and falciparum malaria (476/821 [58.0%]) were the main diseases associated with seizures in neonates and in children six months or older respectively. Falciparum malaria was also the main illness (56/98 [57.1%]) associated with status epilepticus. Other illnesses associated with seizures included pyogenic meningitis, respiratory tract infections and gastroenteritis. Twenty-eight children (3.1%) with seizures died and 11 surviving children (1.3%) had gross neurological deficits on discharge. Status epilepticus, focal seizures, coma, metabolic acidosis, bacteraemia, and pyogenic meningitis were independently associated with mortality; while status epilepticus, hypoxic ischaemic encephalopathy and pyogenic meningitis were independently associated with neurological deficits on discharge.ConclusionThere is a high incidence of acute seizures in children living in this malaria endemic area of Kenya. The most important causes are diseases that are preventable with available public health programs.

Intranasal Midazolam vs Rectal Diazepam in Acute Childhood Seizures

One hundred eighty-eight seizure episodes in 46 children were randomly assigned to receive treatment with rectal diazepam and intranasal midazolam with doses of 0.3 mg/kg body weight and 0.2 mg/kg body weight, respectively. Efficacy of the drugs was assessed by drug administration time and seizure cessation time. Heart rate, blood pressure, respiratory rate, and oxygen saturation were measured before and after 5, 10, and 30 minutes following administration of the drugs in both groups. Mean time from arrival of doctor to drug administration was 68.3 +/- 55.12 seconds in the diazepam group and 50.6 +/- 14.1 seconds in the midazolam group (P = 0.002). Mean time from drug administration to cessation of seizure was significantly less in the midazolam group than the diazepam group (P = 0.005). Mean heart rate and blood pressure did not vary significantly between the two drug groups. However, mean respiratory rate and oxygen saturation differed significantly between the two drug groups at 5, 10, and 30 minutes after drug administration. Intranasal midazolam is preferable to rectal diazepam in the treatment of acute seizures in children. Its administration is easy, it has rapid onset of action, has no significant effect on respiration and oxygen saturation, and is socially acceptable.

Buccal Midazolam for Acute Seizures in Children

Rectal diazepam often is used in children with acute seizures when intravenous access cannot be obtained, but it is associated with risk for seizure