Infection and Inflammation Concerns of a Pediatric Client

Seizures in Children

• General Definition and Incidence:

  • Seizures are the most common pediatric neurological disorder.

  • They are caused by excessive and disorderly neuronal discharges within the brain.

  • Incidence: Approximately $4\text{--}10\%$ of children will experience at least one ($\ge 1$) seizure by the age of $16$.

  • Clinical manifestations depend on the specific region of the brain involved.

• Epilepsy:

  • Defined as having $2$ or more unprovoked seizures occurring more than (>) $24$ hours apart.

  • Approximately $1\%$ of Canadians are affected by epilepsy.

  • In about $50\%$ of childhood cases, the condition remits.

• Etiological Classifications:

  • Acute Symptomatic: Linked to an immediate or recent brain insult, such as head trauma or meningitis.

  • Remote Symptomatic: Occurs due to a prior brain injury where the damage happened in the past but continues to affect brain function (e.g., encephalitis, hypoxia, stroke, or Cerebral Palsy/CP).

  • Cryptogenic: Diagnosed when no clear cause can be identified.

  • Idiopathic: Genetic in origin; occurs without an identifiable structural or metabolic cause. The cause remains unknown in $50\text{--}60\%$ of all cases.

• Pathophysiology and Triggers:

  • Abnormal neuronal discharges occur due to increased ($\uparrow$) excitation and decreased ($\downarrow$) inhibition.

  • These discharges may:

    1. Arise from central areas of the brain that affect consciousness.

    2. Be restricted to one specific area of the cerebral cortex, producing symptoms characteristic of that anatomical focus.

    3. Begin in a localized cortical area and spread to other portions of the brain; if extensive enough, this produces generalized seizure activity.

  • Common triggers: Brain injury, infection, genetics, dehydration, hypoglycemia, electrolyte imbalance, stress, and toxins.

Febrile Seizures

• Simple Febrile Seizures:

  • Affect $2\text{--}5\%$ of children between the ages of $6\text{ months}$ and 5\text{ years, with a peak incidence at 12\text{--}18\text{ months.

  • Characteristics: Generalized tonic–clonic movements, duration less than (<) 15\text{ minutes, and no recurrence within a $24\text{-hour}$ period.

  • Clinical Requirements: Fever greater than (>) $38^{\circ}C$, no Central Nervous System (CNS) infection (e.g., not caused by meningitis or encephalitis), and a normal neurological status before and after the event.

  • Management: Most seizures stop before the child reaches the hospital. Antipyretics (such as Tylenol) are used for comfort only and do not decrease the risk of having a febrile seizure or prevent recurrence. Tepid (cool) baths are NOT recommended as they cause discomfort and increase metabolic demand without benefit.

• Complex Febrile Seizures:

  • Features: Duration greater than (>) 15\text{ minutes, focal onset (rather than generalized), and may recur within 24\text{ hours.

  • Implications: There is a higher risk of developing epilepsy later. Management may involve acute administration of benzodiazepines if the seizure is prolonged and investigations to rule out CNS infection or metabolic causes.

Seizure Classification and Diagnostic Evaluation

• Classification by Onset:

  • Focal Onset: (Formerly partial) Begins in one area of the brain. Awareness may be preserved or impaired. Can include motor symptoms (jerking, stiffness) or non-motor symptoms (sensory changes, emotional shifts). Can evolve into focal-to-bilateral tonic-clonic seizures.

  • Generalized Onset: Involves both hemispheres from the start. Includes motor types (tonic-clonic) and non-motor types (absence seizures involving blank staring).

  • Unknown Onset: The beginning is not observed or is unclear.

• Diagnostics:

  • Detailed History: Essential context includes what the child was doing before the event, the mode of onset, duration, specific movements, and recovery behavior.

  • EEG (Electroencephalogram): The most useful initial test to confirm diagnosis and determine seizure type. Note: A standard EEG only captures about one ($1$) hour of activity; prolonged monitoring may be needed.

  • Neuroimaging/Metabolic Panels: Indicated for complex or prolonged seizures or abnormal neurological exams to define underlying causes.

Therapeutic Management of Seizures

• Medication Therapy:

  • First-line treatment: Antiepileptic drugs work by raising the seizure threshold and suppressing abnormal discharges.

  • Strategy: Start with monotherapy and adjust doses; add a second drug only if necessary. Monitor for side effects like sleepiness, ataxia, or mood changes.

  • Tapering: If the child is seizure-free for two ($\ge 2$) years, medications may be tapered slowly.

• Ketogenic Diet:

  • Structure: High fat, low carbohydrate, and adequate protein to induce ketosis.

  • Early Side Effects: Diarrhea, hypoglycemia, dehydration, acidosis, lethargy. Watch for hidden sugars in other medications.

  • Long-term Risks: Dyslipidemia, kidney stones, and poor growth.

• Vagus Nerve Stimulation (VNS):

  • Used for patients aged twelve ($\ge 12$) years and older with refractory focal seizures.

  • Method: An implanted pulse generator in the upper chest sends electrical impulses to the left vagus nerve. A handheld magnet can be used by the family at the onset of a seizure to trigger extra stimulation.

• Surgical Therapy:

  • Reserved for refractory seizures or structural lesions (tumors, hematomas).

  • Options: Focal resection (removing the epileptogenic zone), Hemispherectomy (removing all/most of one hemisphere), or Corpus callosotomy (disconnecting hemispheres to block the spread of discharges).

Nursing Care and Safety for Seizures

• During a Seizure:

  • Stay calm and time the episode.

  • Ease the child to the floor, loosen clothing, and remove glasses.

  • Turn the child to their side if vomiting occurs to protect the airway.

  • DO NOT restrain the child or put objects in their mouth. DO NOT give food or fluids.

• General Safety:

  • Use padded side rails in the hospital.

  • During activities: Swim only with a companion, supervised bathing (no locked doors), and use helmets for biking/skating.

  • Teens must follow provincial regulations regarding driving and hazardous machinery (usually requiring a designated seizure-free period).

Status Epilepticus (SE)

• Definition: A medical emergency characterized by continuous seizure activity for five ($\ge 5$) minutes or longer, or three ($\ge 3$) or more seizures within a $15\text{-minute}$ period without return to baseline consciousness.

• Risks: Seizures exceeding $30\text{ minutes}$ pose a high risk for neuronal injury and cognitive deficits.

• Pharmacological Treatment:

  • Pre-hospital/Initial: Lorazepam, Midazolam, or Diazepam.

  • In-hospital First-line: IV Lorazepam or IV/IN Midazolam.

  • Second-line: IV Fosphenytoin, Phenytoin, or Phenobarbital.

  • Refractory SE: Requires continuous infusions (Midazolam, Propofol, or Pentobarbital), intubation, mechanical ventilation, and continuous EEG monitoring.

• Nursing Priority: Manage Airway, Breathing, and Circulation (ABCs). Monitor ECG and Blood Pressure (BP) for risks of arrhythmia and hypotension.

Meningitis: Acute Inflammation of the Meninges

• Overview: Meningitis is a life-threatening inflammation of the meninges, classified as Aseptic (usually viral) or Bacterial.

• Bacterial Meningitis Pathophysiology:

  • Infection spreads via the bloodstream to the Cerebrospinal Fluid (CSF).

  • Triggered inflammation leads to cerebral edema and purulent exudate (thick, yellowish buildup of inflammatory cells, bacteria, and debris).

  • Exudate can obstruct CSF flow, significantly increasing Intracranial Pressure (ICP).

• Aseptic (Viral) Meningitis:

  • Triggers a milder inflammatory response without purulent exudate. Usually self-limiting and requires supportive treatment.

• Clinical Presentation:

  • Children/Adolescents: Abrupt onset of fever, chills, headache, vomiting, and altered sensorium.

  • Classic Signs:

    • Nuchal Rigidity: Stiffness/resistance to passive neck flexion.

    • Brudzinski’s Sign: Passive neck flexion causes involuntary hip and knee flexion.

    • Kernig’s Sign: Pain/resistance when straightening the leg at the knee while the hip is flexed at $90^{\circ}$.

  • Infants/Toddlers: Bulging fontanel (indicating increased ICP), fever, poor feeding, and a high-pitched ‘neuro cry’.

  • Newborns: Extremely difficult to diagnose; symptoms are vague (poor tone, weak cry, refusal of feeding).

  • Rash: A petechial (pin-prick) or purpuric (bruise-like) rash is a marker of severe meningococcal disease.

• Diagnostic Evaluation (CSF Analysis):

  • Bacterial: Cloudy appearance, increased ($\uparrow$) protein, decreased ($\downarrow$) glucose, positive Gram stain, and very high white blood cell (WBC) count.

  • Aseptic: Clear appearance, normal or slightly increased protein, normal glucose, negative Gram stain, and slightly increased WBC count.

  • Pre-procedure Caution: Rule out mass effect/midline shift on CT before Lumbar Puncture (LP) to prevent brain herniation.

Therapeutic and Nursing Management of Meningitis

• Emergent Care: Rapid initiation of broad-spectrum IV antibiotics (covering Gram-positive and Gram-negative organisms). Isolation precautions (Droplet) should be initiated. Stabilization of ABCs is the priority.

• Ongoing Medical Management:

  • Reduce ICP: Elevate head of bed (HOB), keep head midline, and reduce stimulation.

  • Temperature and Seizure Control: Fever and seizures increase metabolic demand and worsen neurological injury.

  • Fluid Balance: Strict monitoring of Intake and Output (I\&O) and daily weights to avoid fluid overload and worsened cerebral edema.

• Long-term Considerations: Approximately $10\%$ of bacterial cases are fatal. Survivors are monitored for hearing impairment (damage to the cochlea) and developmental delays.

Tonsillitis

• Anatomy: Tonsils are masses of lymph tissue that filter and protect the respiratory tract. They are larger in children than in teenagers.

• Manifestations: Sore throat, difficulty swallowing, fever, enlarged nodes, bad breath (mouth breathing), and muffled voice.

  • Airway Obstruction: "Kissing" tonsils (enlarged palatine tonsils) cause difficulty breathing; enlarged adenoids cause snoring and sleep apnea.

• Management:

  • Viral: Symptomatic treatment (fluids, rest).

  • Bacterial: Specifically Group A Beta-Hemolytic Streptococcus (GABHS), requires antibiotics.

  • Surgical: Tonsillectomy/Adenoidectomy (T\&A) is indicated for recurrent infections ($6$ episodes/year or $20$ days missed school) or sleep apnea.

• Post-Operative Nursing Care:

  • Minimize surgical site disturbance: Avoid coughing, straws, and nose blowing.

  • Pain management: Administer analgesics around the clock for at least $48\text{ hours}$.

  • Diet: Clear liquids first; progress to soft foods. Avoid red fluids (can mimic blood) and dairy (coats throat, stimulates coughing).

  • Hemorrhage Monitoring: Watch for frequent/continuous swallowing or clearing of the throat, restlessness, or vomiting of fresh blood.

  • Critical Risk Windows: Within the first $24\text{ hours}$, and again at $7\text{--}10$ days (up to $14$ days) post-op when the scab sloughs off.

Glomerulonephritis and APSGN

• Pathophysiology: An immune-mediated process where immune complexes (Anti-GBM antibodies and complement) deposit along the Glomerular Basement Membrane (GBM). This results in inflammation and impaired filtration, leading to water and sodium retention.

• Acute Post-Streptococcal Glomerulonephritis (APSGN):

  • The most common form in children; develops $5\text{--}21$ days after a Group A Strep infection.

  • Peak incidence: $6\text{--}7\text{ years}$; more common in males.

• Signs/Symptoms: Edema, hypertension, tea-colored urine (hematuria), decreased urine output, and costovertebral angle tenderness.

• Diagnostic Tests:

  • BUN/Creatinine: Elevated levels indicate impaired kidney function.

  • Urine: Dipstick shows $3+$ to $4+$ blood and protein.

  • ASO Titer: Indicates recent strep infection (does not diagnose GN itself).

  • C3 Complement Levels: Serum levels are low during active injury; Rising C3 levels indicate clinical improvement.

• Therapeutic Management:

  • Rest and dietary restrictions (Sodium, Potassium, and Fluids).

  • Medications: Antihypertensives and Diuretics. Antibiotics are only used if a persistent strep infection is present.

Questions & Discussion

• Seizure Reflective Questions:

  • What safety precautions should be in place for a patient at risk of seizures in the hospital?

  • How would you modify the environment to reduce injury risk?

  • What are the interprofessional roles in a seizure emergency?

• Meningitis Family Support:

  • A 3-month-old infant is diagnosed with bacterial meningitis. The parents feel guilty for not recognizing signs sooner.

  • What teaching and emotional support should be provided?

  • What are the interprofessional responsibilities for this family?

• Tonsillectomy Scenario:

  • A child is arriving via ambulance with a post-T\&A bleed.

  • What is the anticipated plan of care? How can you prepare to treat the child safely?

• Glomerulonephritis Group Work Case Study:

  • Patient: 4-year-old Robert, tea-colored urine, recent strep throat ($10$ days ago), BP $135/65$.

  • Assessment: What are your primary evaluation areas and questions for the family?

  • Complications: What happens if GN is untreated? How do you monitor for improvement or worsening?

  • Nursing Action: What should you do if the child complains of a headache and blurred vision? (Note: These suggest hypertensive encephalopathy).

  • Education: What diet should be avoided? Can the child return to daycare?