Pediatric Primary Care (117 page)

1.  Cyproheptadine (Periactin): 0.25-0.4 mg/kg or 2-4 mg daily bid.

2.  Amitriptyline: start 10 mg at bedtime.  Up to 1-2 mg/kg at bedtime.

3.  Propranolol (Inderal): 1-2 mg/kg/day up to 4 mg/kg/day bid.  Unless using LA form.

4.  Tizanidine (Zanaflex): 2-4 mg at bedtime up to 12 mg.  Monitor hepatic panel at 1, 3, and 6 months.

5.  Valproic acid (Depakote): 10-20 mg/kg bid up to 60 mg/kg.

6.  Topiramate (Topamax): titrate to 50 mg bid.

7.  Verapamil: 40 mg tid or SR 120 mg, 180 mg, 240 mg daily.

B.  Abortive:

1.  Sumatriptan (Imitrex NS): 5-10 mg (1-2 sprays).  Oral 25 mg up to 100 mg.

2.  Rizatriptan (Maxalt): 5 -10 mg tab.

3.  Dihydroergotamine mesylate (Migranal): 1 spray each nostril, may repeat in 15 minutes.

4.  Zolmitriptan (Zomig): 2.5-5 mg tab; 5 mg NS.

5.  Eletriptan (Relpax): 20-40 mg tab.

6.  Metoclopramide (Reglan): 0.1-0.2 mg/kg/dose up to 4 times a day.

7.  Promethazine (Phenergan): 0.25 mg/kg/dose (max 25mg) up to 4 times a day.

8.  Ibuprofen: 15 mg/kg/dose every 6 hours.

9.  Acetaminophen (Tylenol): 10 mg/kg/dose every 4 hours.

X.  FEBRILE SEIZURES

A.  Seizure in association with a febrile illness in the absence of central nervous system infection or acute electrolyte imbalance in children older than 3 months of age without a prior afebrile seizure.

B.  Etiology.

1.  Benign age-dependent epilepsy syndrome, seizure in early life in presence of fever without intracranial infection.

2.  Genetic disposition–two to three times more common among family members of affected children than general population.

C.  Occurrence.

1.  2-5% of children will have a febrile seizure.

2.  Most common between ages of 6 months to 3 years, with peak incidence at 18 to 24 months of age.

3.  Risk factors.

a.  High peak temperature during illness.

b.  Family history of febrile seizures in a first- or second-degree relative.

c.  Developmental delay.

d.  Neonatal nursery stays longer than 30 days.

e.  Attendance at daycare.

D.  Physical findings.

1.  Temperature of at least 39°F.

2.  Simple febrile seizure.

a.  Generalized tonic-clonic movements.

b.  Eyes roll back.

c.  Loss of consciousness.

d.  Last few seconds to minutes (less than 15 minutes).

e.  Postictal depression is brief.  

3.  Complex febrile seizures.

a.  Last longer than 15 minutes.

b.  May reoccur within the same day.

c.  Prolonged period of postictal drowsiness or neurological abnormalities.

d.  Focal seizure manifestations.

E.  Diagnostic tests.

1.  Simple febrile seizure.

a.  Extensive history taking.

b.  Evaluation for cause of fever, CBC.

c.  LP for infants younger than 6 months of age.

2.  Complex febrile seizure.

a.  CSF evaluation.

b.  Head CT if warranted.

c.  EEG if concerned.

F.  Differential diagnosis.

G.  Treatment.

1.  Control fever with antipyretic medication.

2.  Antibiotics appropriate for any bacterial infections.

3.  Treat cause of fever, fluids.

4.  Diazepam rectally or lorazepam (Ativan) IV for seizures lasting longer than 5 minutes.

5.  No need for anticonvulsant medication.

H.  Complications.

1.  Rare, no neurological sequelae.

2.  Fewer than 10% of patients experience severe or recurrent attacks.

3.  Likelihood of developing epilepsy less than 5%.

4.  Possible complications if septic nature is cause for fever and seizure.

5.  Risk for reoccurrence.

a.  Neurological or developmental abnormality.

b.  Positive family history.

c.  Onset of febrile seizures before age 1 year.

d.  Low peak temperature at onset of seizure.

e.  Duration of fever.

I.  Follow up.

1.  Any seizure without fever.

2.  As needed for treatment of cause of fever.

J.  Education.

1.  Reassurance of the benign nature.

2.  First aid during a seizure.

3.  When to call the doctor or go to the emergency room: Need to find and treat cause of fever, to stop seizure that continues past 5 minutes and does not stop with diazapam rectal (Diastat).

XI.  GENERALIZED SEIZURES

A.  Seizure in which the first clinical changes indicate initial involvement of both hemispheres.

B.  Etiology.

1.  Up to 80% have unclear etiology.

2.  Hereditary.

3.  Perinatal: infectious, hypoxia, trauma.

4.  Metabolic, toxic, nutritional.

5.  Infectious.

6.  Vascular.

7.  Neoplastic.

C.  Occurrence.

1.  Children account for about 15% of all epilepsy cases.

2.  Generalized seizures account for one-third of all epilepsies.

3.  Most often start in childhood or adolescence.

D.  Clinical manifestations.

1.  Generalized tonic-clonic (grand mal).

a.  Starts suddenly with stiff muscles (tonic phase) and then rhythmic contractions (clonic phase).

b.  Impaired consciousness.

c.  Loss of bladder control common.

d.  Can last a few minutes.

e.  Postictal phase that can include drowsiness, confusion, and headache.

2.  Atonic seizure (drop attack).

a.  Sudden drop to the floor, head may nod/drop.

b.  Brief episode, loss of consciousness brief.

c.  Injuries are common.

3.  Absence seizures.

a.  Abrupt sudden loss of consciousness with cessation of all motor activity.

b.  Brief periods of staring blankly into space.

c.  Ends abruptly, no postictal state.

d.  Can be induced by hyperventilation.