The results of the North London Convulsive Status Epilepticus in Childhood Surveillance Study (NLCSESS) [1] are used to develop a new treatment protocol, by researchers at the Institute of Child Health, and Great Ormond Street Hospital for Children, London, UK. Status epilepticus is defined as a seizure or series of seizures that last for 30 min or more without regaining consciousness between seizures [2]. A definition used for treatment purposes includes continuous seizure activity lasting 5 min, and is termed potential status epilepticus. The study was for 2 years up to the 16th birthday and neonates were excluded. The incidence of CSE in this population was 17- 23/100,000 children per year. Prolonged febrile seizures were the most common cause, occurring in 32% of the total of 304 episodes of CSE. Etiology was acute symptomatic in 17%, remote symptomatic in 16%, previous epilepsy in 12%, and unknown in 7%. Age incidence was mainly 0-4 years. Incidence was increased in Asian (Indian and Pakistani) ethnic groups, and with poor socioeconomic status. Acute bacterial and virus CNS infections accounted for 19% of CSE with fever. Seizures were focal in onset in 36%, becoming generalized in 95%; 60% lasted longer than 60 min. CSE recurred in 17% in 1 year. Mortality of 3.4% was related to the cause (bacterial meningitis, metabolic or neurodegenerative disorder).

Analysis of data extracted from the NLCSESS population-based study supported the use of iv lorazepam as first-line treatment of CSE in preference to rectal diazepam, and iv phenytoin as second-line treatment. Prehospital treatment is important, but doses of benzodiazepine should be limited to 2, to avoid respiratory depression. Management of an underlying acute symptomatic cause is as important as stopping the seizure in terms of longterm outcome. Treatment for possible bacterial meningitis should begin early in a child with febrile CSE and while the child is investigated. [3]

COMMENT. This article was presented at an International Symposium on Status Epilepticus in Infants and Young Children in Japan, April 2006. Other papers presented and published in this supplement include “Treatment of convulsive status epilepticus (CSE)” by Sugai K, and “Hippocampal volumes and diffusion-weighted image findings in children with prolonged febrile seizures” by Natsume J et al. Sugai lists the causes of CSE in his tertiary hospital as intractable epilepsies (34-49%), CNS infections (14-28%), febrile seizures (13-23%), metabolic disorders (3-5%), and cerebrovascular (1-3%). In a city hospital in Japan, the most frequent cause was complex febrile seizures (57%); epilepsies accounted for 22%, and CNS infections (5%). The most commonly used treatments for CSE in Japan are diazepam, phenytoin, and barbiturates as 1st, 2nd, and 3rd-line drugs. Midazolam i.v has recently become a more favorable 2nd line drug. [4]

Natsume and colleagues findings of hippocampal pathology following prolonged febrile seizures provide further evidence of risk of mesial temporal sclerosis (MTS) and temporal lobe epilepsy (TLE) as late complications of childhood febrile seizures. Scott RC et al postulated that MTS nay develop after a lag period (Ped Neur Briefs Oct 2006;20:77) [5, 6]. Neurosurgical experience has shown that adult patients with TLE associated with MTS are more likely to have a childhood history of febrile seizures than those without MTS [7]. Perhaps the “benign” nature of febrile seizures has been overemphasized. Efforts to prevent recurrence and rapidly abort febrile seizures should be given more attention, especially in patients with a first complex febrile seizure.