Afebrile Seizures in Children

A seizure is a sudden event characterized by behavior change of the patient and afebrile one simply means, there is no associated fever. It is caused by abnormal and excessive activity of a group of neurons (specialized cells that transmit nerve impulses in the brain).Occurrence and appearance of a seizure is dependent on thelocation and extent of brain damage. 

How do seizures occur?
Like mentioned above, it occurs when a large number of neurons in the brain are discharged in anabnormalway. Depending on affected area, it can be a generalized or partial seizure.

Epilepsy is defined as occurrence of two or more unprovoked seizures. It occurs frequently in children due to their immature nervous system and if not treated adequately can put the child at a risk for cognitive andbehavioral abnormalities.

Classification of seizure types

Whenever a child comes at the emergency, it is important to evaluate the type;

Partial seizures– involve a portion of the brain at onset, associated with lack of complete loss of consciousness. However, they are also divided into two; Simple partial seizure and complex partial seizures. The former, does not impair consciousness while the latter does. Simple partial seizures, present with focal signs like focal clonic movement, arrest of movement and speech.

Complex partial seizures on the other hand present with staring spells, blinking, fumbling or cloth pricking. At this state, the patient is unconscious.

Generalized seizures

Characterized by sudden loss of consciousness.

They are divided into convulsive and no convulsive seizures.

Convulsive generalized seizures

This entails tonic-clonic which begins with sudden loss of consciousness, followed by jerky movements and after that the patient falls asleep, urinates on them or cry. Clonic one occurs by jerky movement and tonic, the patient is unconscious.

Non-convulsive generalized seizures

Involves absence, myoclonic, tonic and atonic seizures. Absence is brief and last few seconds arresting movement and consciousness. The mother may report a fixed stare of the baby or patient holding a glass and it falls unknowingly. Myoclonic involves twitching of a particular group of muscles. Atonic involves loss of muscle tone and this can lead to the patient falling sustaining other injuries.

Diagnosis

A detailed history from the parents or anyone who witnessed the seizure is paramount.

Carefully neurological exam can be done to detect any probable cause like increased intracranial pressure.

Blood works may show elevated white blood count especially in prolonged seizures.

Electroencephalogram (EEG) is the most important radiological exam for seizure.

Treatment

A wide number of seizures are self-limiting, first contact with patient at home the parents are advised to ensure the surrounding is safe for the child to avoid injuries.

At the emergency department, the child may be put on anti convulsants like benzodiazepines especially I.V diazepam 0.2-0.5mg/kg (max 10mg) and per rectal diazepam 0.5mg/kg (max 20mg) or I.V lorazepum 0.1mg/kg (max 8mg)

Long-term anticonvulsant treatment

Phenytoin, carbamazepine, phenobarbital and valproic acid are excellent choices for generalized and partial seizures. However, any choice has its limitations. Commonly used is the carbamazepine class.

As a parent, it is important to look out for such symptoms and bring your child for evaluation to avoid complications later on.

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Paraphimosis

This is the inability to retract the foreskin of uncircumcised male above the glans penis (head of penis), leading to compromised blood supply to the penis.
It is good to distinguish it from Phimosis, which is the inability of the foreskin to retract from the head of the penis partially or completely.
Predisposing Factors
Infections - this is one of the commonest cause in young males, any infection around the foreskin can lead to inflammation (swelling) leading to unretract able foreskin above the head of the penis.
Trauma - In young males, the zipper of the trouser can pinch the foreskin forcefully pulling it back from the head.
Masturbation -Commonly seen with teenage males who are on sexual discovery, forcefully pulling the skin back.
Iatrogenic cause - this happens during examination of the penis by the doctor and somehow the skin fails to retract back to its normal position, prior to the examination.
Clinical Features
Paraphimosis is a clinical diagnosis.
The patient’s parents may report history of retracting the skin prior to onset of the symptoms.
The patient looks anxious because of the pain due to compromised blood supply.
It is important as well to ensure the patient is uncircumcised because hair tourniquet syndrome can mimic the condition.
The foreskin looks swollen at the unretractable point and red.
Treatment
Paraphimosis is a urological Emergency.Therefore, treatment should be instituted fast to relief the vascular compromise that is going on.
Pain can be controlled by oral pain medications or intravenous (veins).
The doctor may try to gently pull the skin back to its original place.
The doctor may also use a needle to burst the inflamed skin to release the swelling.
The above measures may fail and circumcision settled as the best alternative.
As a parent, it is important to look out for the above and save your baby’s life. Ensure the baby is dressed in underwear before putting on a trouser or a short with a zipper. At home before accessing a health facility, you can place ice cubes on the unretractable skin to relief the swelling and pain.

Phimosis

Over time, you may have heard of the word from the doctor concerning the male child. This condition is common and in many hospitals set up it can be an indication of circumcision.
Phimosis per se is the constriction of the foreskin leading to the failure to retract the foreskin over the glans. In most cases, the male child is born with it. As the child grows, by four years, the skin is retractile. However, not all male children by this age have their foreskin retractile.
Possible causes of phimosis
Trauma- any injury to the foreskin can lead to healing by fibrosis or scarring.
Infections-any bacterial or viral infection around the male genitalia causing the tight foreskin
Poor Hygiene-if the baby’s genitalia is not cleaned well can lead to infections hence tightening the foreskin around the glans penis.
Clinical Features
The doctor can diagnose the condition clinically.
History of foreskin unretract able can suggest the condition.
Management
It is important to note as a parent that Phimosis is age related. As the baby grows the skin might retract.
It is good to maintain good hygiene and ensure the baby is passing urine with ease.
If there are symptoms of infections, take the baby to the doctor.
In failure, visit a urologist who may administer the appropriate management including;
Circumcision, Preputial plasty and Balloon dilatation. However, use of Betamethasone valerate 0.6% twice daily for two weeks has shown successful treatment of true Phimosis.
If the patient is able to urinate and no signs of infections, the urologist can buy time and enroll the patient on follow up till the foreskin retracts.

Appendicitis

Appendicitis is a common disorder affecting approximately 6 percent of the population. Atimes it is hard to make a correct diagonis since not all patients present with the classical signs and symptoms.
Clinical Features
Abdominal pains- Localised on the right lower quadrant.
Nausea
Vomiting- Proceeds the abdominal pains

On palpation, the McBurney's point is the location of maximum tenderness
There are signs the clinician can use to elicit appendicitis. They include Rovsing's sign,Psoas sign and Obturator sign.
Treatment
The inflammed appendix is removed as a surgical procedure is done
Prior to surgery, the patient is starved and put on antibiotics.