Postnatal Steroids and Febrile Seizure Susceptibility in Preterm Children

Febrile Seizures: An Updated Narrative Review for Pediatric Ambulatory Care Providers

BACKGROUND

While generally self-limited, febrile seizures result in significant familial distress. Ambulatory pediatric care providers must be prepared to counsel families on the causes, risk factors, management principles, and prognosis of children with febrile seizures.

OBJECTIVE

To provide an updated, evidence-based review of febrile seizures focused on the needs of an ambulatory pediatric care provider.

METHODS

A narrative review of the literature prioritizing landmark articles, metanalyses, longitudinal population longitudinal cohort studies and national level guidelines.

RESULTS

Febrile seizures are aberrant physiological responses to fever in children caused by complex interactions of cytokine mediated neuroinflammation, environmental triggers, and genetic predisposition. Other than investigations to determine fever etiology, routine bloodwork, lumbar punctures, neuroimaging and electroencephalograms are low yield. The general prognosis is excellent, however, clinicians should be aware of long-term outcomes including: cognitive impairment with non-simple febrile seizures; neuropsychiatric associations; recurrent febrile seizure and epilepsy risk factors; and the association between complex febrile seizures and sudden unexpected death. Children with a high risk of recurrence, complex febrile seizures, limited access to care, or extreme parental anxiety may benefit from intermittent oral diazepam prophylaxis.

CONCLUSION

Clinicians should consider four management priorities: 1) terminating the seizure; 2) excluding critical differential diagnoses; 3) investigating fever etiology; and 4) providing adequate counselling to families. The clinical approach and prognosis of febrile seizure can be based on subtype. Children with non-simple (i.e. complex or febrile status epilepticus) febrile seizures require closer care than the vast majority of children with simple febrile seizures, who have excellent outcomes.

Completeness of Retention Data and Determinants of Attrition in Birth Cohorts of Very Preterm Infants: A Systematic Review

Background: Birth cohorts provided essential knowledge for clinical and public health decision-making. However, little is known about retention and determinants of attrition in these specific longitudinal studies, although characterizing predictors of attrition sets the path to mitigate its occurrence and to promote valid inferences. We systematically reviewed retention in follow-ups of birth cohorts of very preterm or very low birth weight infants and the determinants of attrition. PROSPERO registration number: CRD42017082672. Methods: Publications were identified through PubMed®, Scopus, Web of Science, and Cochrane Library databases from inception to December 2017. Studies were included when reporting at least one of the following: retention at follow-ups, reasons for attrition, or characteristics of non-participants. Quality assessment was conducted using the completeness of the report of participation features in the articles. Non-participant's characteristics were presented using descriptive statistics. Local polynomial regression was used to describe overall retention trends over years of follow-up. Results: We identified 57 eligible publications, reporting on 39 birth cohorts and describing 83 follow-up evaluations. The overall median retention was 87% (p25-p75:75.8-93.6), ranging from 14.6 to 100%. Overall, retention showed a downward trend with increasing child age. Completeness of retention report was considered "enough" in only 36.8% of publications. Considering the 33 (57.9%) publications providing information on participants and non-participants, and although no formal meta-analysis was performed, it was evident that participants lost to follow-up were more often male, had foreign-born, multiparous, and younger mothers, and with a lower socioeconomic status. Conclusion: This systematic review evidenced a lack of detailed data on retention, which may threaten the potential use of evidence derived from cohort studies of very preterm infants for clinical and public health purpose. It supports the requirement for a standardized presentation of retention features responding to current guidelines.

Early Neurodevelopmental Trajectories for Autism Spectrum Disorder in Children Born Very Preterm

BACKGROUND

Children born preterm are at high risk for autism spectrum disorder (ASD). However, there is still a lack of appropriate developmental markers. In this study, we aim to examine whether early mental performance trajectory is related to ASD outcome in the preterm population.

METHODS

The population-based cohort included 414 very preterm survivors born between 2008 and 2014. After excluding children with severe neurosensory impairment, 319 children with available records of developmental quotients before age 2 years were enrolled. The trajectory of mental performance evaluated by using the Bayley Scales of Infant Development across 6, 12, and 24 months of age was analyzed with group-based trajectory modeling. At 5 years of age, the ASD diagnosis was established by using the Autism Diagnostic Observation Schedule and the Autism Diagnostic Interview-Revised.

RESULTS

There were 29 children with ASD and 290 children without ASD. The mental performances from age 6 to 24 months could be classified into 3 trajectory patterns: low declining, high declining, and high stable, which corresponded to ASD prevalence at age 5 years of 35%, 9%, and 3%, respectively. ASD odds was 15 times higher in the low-declining group than in the high-stable group (odds ratio 15; 95% confidence interval 3.8-59; P < .001). Through the analysis of multinomial logistic regression, we found that male infants with longer exposure to oxygen therapy whose mothers had lower maternal education levels tended to follow the low-declining trajectory.

CONCLUSIONS

The early-life mental trajectory patterns, by using the Bayley Scales of Infant Development, may lead to identification of vulnerable children born preterm for early ASD diagnosis and targeted intervention.

Behavioral characteristics of autism spectrum disorder in very preterm birth children

Background

Lower gestational age may increase autism spectrum disorder (ASD) vulnerability; however, the incidence of ASD diagnosis through a direct assessment on every very preterm birth child on the population base remains unclear. Moreover, the behavioral characteristics of preterm birth ASD are unknown.

Methods

Every very preterm birth child (gestational age < 32 weeks; birth weight < 1500 g) who was discharged from neonatal intensive care units in Southern Taiwan and prospectively followed to 5 years of age was evaluated using the Autism Diagnostic Observation Schedule (ADOS) and the Autism Diagnostic Interview-Revised (ADI-R). The term birth (gestational age > 37 weeks) ASD children characterized by ADOS and ADI-R were group matched to the preterm birth ASD by age at examination for comparison. ADOS severity scores were calculated by the Mann-Whitney U test and ADI-R by multivariate analysis of variance and canonical discriminant analysis.

Results

Two hundred forty-six (87%) of the 283 very preterm survivors were followed prospectively to 5 years of age. Nineteen (7.7%) of the 246 children fulfilled the diagnostic criteria of ASD. After excluding 1 patient with cerebral palsy and profound mental disability, 18 preterm ASD children were compared with 44 term birth ASD children. The two ASD groups were comparable for age at examination, gender, and intelligence quotient. The two groups showed comparable ADOS severity scores in social affect deficits, restricted repetitive behaviors, and total score, but had differences in qualitative abnormalities in reciprocal social interaction (Wilks lambda F value = 6.2, P < 0.001) of ADI-R. Compared to term birth ASD children, preterm birth ASD children exhibited worse nonverbal behaviors that regulate social interaction (OR 2.59, 95% CI 1.41-4.73, P = 0.002) but more favorable peer relationships (OR 0.58, 95% CI 0.38-0.90, P = 0.01) and socioemotional reciprocity (OR 0.55, 95% CI 0.33-0.92, P = 0.02). In contrast to the heterogeneous severity of social reciprocity in the term ASD group, the behavioral characteristics of the preterm ASD group showed a homogeneous reciprocal social interaction pattern.

Conclusions

The 5-year incidence rate of ASD was high in very preterm birth children. Preterm birth ASD exhibited a specific behavioral phenotype of reciprocal social interaction.

Febrile seizures: an overview

Background

Febrile seizures are the most common neurologic disorder in childhood. Physicians should be familiar with the proper evaluation and management of this common condition.

Objective

To provide an update on the current understanding, evaluation, and management of febrile seizures.

Methods

A PubMed search was completed in Clinical Queries using the key terms ‘febrile convulsions’ and ‘febrile seizures’. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews.

Results

Febrile seizures, with a peak incidence between 12 and 18 months of age, likely result from a vulnerability of the developing central nervous system to the effects of fever, in combination with an underlying genetic predisposition and environmental factors. The majority of febrile seizures occur within 24 hours of the onset of the fever. Febrile seizures can be simple or complex. Clinical judgment based on variable presentations must direct the diagnostic studies which are usually not necessary in the majority of cases. A lumbar puncture should be considered in children younger than 12 months of age or with suspected meningitis. Children with complex febrile seizures are at risk of subsequent epilepsy. Approximately 30–40% of children with a febrile seizure will have a recurrence during early childhood. The prognosis is favorable as the condition is usually benign and self-limiting. Intervention to stop the seizure often is unnecessary.

Conclusion

Continuous preventative antiepileptic therapy for the prevention of recurrent febrile seizures is not recommended. The use of intermittent anticonvulsant therapy is not routinely indicated. Antipyretics have no role in the prevention of febrile seizures.

Update on Postnatal Steroids

Antenatal steroid treatment to enhance fetal lung maturity and surfactant treatment to prevent or treat respiratory distress syndrome have been major advances in perinatal medicine in the past 40 years contributing to improved outcomes for preterm infants. Use of postnatal steroids to prevent or treat chronic lung disease in preterm infants has been less successful and associated with adverse neurodevelopmental outcomes. Although early (in the first week of life) postnatal steroid treatment facilitates earlier extubation and reduces the risk of chronic lung disease, it is associated with adverse effects, such as hyperglycemia, hypertension, gastrointestinal bleeding and perforation, hypertrophic cardiomyopathy, growth failure, and cerebral palsy, and cannot be recommended. Early treatment with hydrocortisone may also improve survival without chronic lung disease, but concerns remain about possible adverse effects such as gastrointestinal perforation and sepsis, particularly in very preterm infants. Early inhaled budesonide also reduces the incidence of chronic lung disease but there are concerns that this may occur at the expense of increased risk of death. More studies of early low-dose steroids with adequate long-term follow-up are needed before they can be recommended for the prevention of chronic lung disease. Late (after the first week of life) postnatal steroids may have a better benefit-to-harm ratio than early steroids. A Cochrane Review shows that late steroid treatment reduces chronic lung disease, the combination of death and chronic lung disease at both 28 days and 36 weeks' corrected age, and the need for later rescue dexamethasone. Adverse effects include hyperglycemia, hypertension, hypertrophic cardiomyopathy, and severe retinopathy of prematurity but without an increase in blindness. Long-term neurodevelopmental effects are not significantly increased by late postnatal steroid treatment. Current recommendations are that postnatal steroid treatment should be reserved for preterm infants who are ventilator-dependent after the first 7-14 days of life and any course should be low dose and of short duration to facilitate endotracheal extubation. Budesonide/surfactant mixtures show some promise as a means of reducing chronic lung disease in preterm infants with severe respiratory distress syndrome, but further larger studies with long-term follow-up are needed before this treatment can be recommended as a routine intervention.