Summary Background Phenytoin is the recommended second-line intravenous anticonvulsant for treatment of paediatric convulsive status epilepticus in the UK; however, some evidence suggests that levetiracetam could be an effective and safer alternative. This trial compared the efficacy and safety of phenytoin and levetiracetam for second-line management of paediatric convulsive status epilepticus. Methods This open-label, randomised clinical trial was undertaken at 30 UK emergency departments at secondary and tertiary care centres. Participants aged 6 months to under 18 years, with convulsive status epilepticus requiring second-line treatment, were randomly assigned (1:1) using a computer-generated randomisation schedule to receive levetiracetam (40 mg/kg over 5 min) or phenytoin (20 mg/kg over at least 20 min), stratified by centre. The primary outcome was time from randomisation to cessation of convulsive status epilepticus, analysed in the modified intention-to-treat population (excluding those who did not require second-line treatment after randomisation and those who did not provide consent). This trial is registered with ISRCTN, number ISRCTN22567894. Findings Between July 17, 2015, and April 7, 2018, 1432 patients were assessed for eligibility. After exclusion of ineligible patients, 404 patients were randomly assigned. After exclusion of those who did not require second-line treatment and those who did not consent, 286 randomised participants were treated and had available data: 152 allocated to levetiracetam, and 134 to phenytoin. Convulsive status epilepticus was terminated in 106 (70%) children in the levetiracetam group and in 86 (64%) in the phenytoin group. Median time from randomisation to cessation of convulsive status epilepticus was 35 min (IQR 20 to not assessable) in the levetiracetam group and 45 min (24 to not assessable) in the phenytoin group (hazard ratio 1·20, 95% CI 0·91–1·60; p=0·20). One participant who received levetiracetam followed by phenytoin died as a result of catastrophic cerebral oedema unrelated to either treatment. One participant who received phenytoin had serious adverse reactions related to study treatment (hypotension considered to be immediately life-threatening [a serious adverse reaction] and increased focal seizures and decreased consciousness considered to be medically significant [a suspected unexpected serious adverse reaction]). Interpretation Although levetiracetam was not significantly superior to phenytoin, the results, together with previously reported safety profiles and comparative ease of administration of levetiracetam, suggest it could be an appropriate alternative to phenytoin as the first-choice, second-line anticonvulsant in the treatment of paediatric convulsive status epilepticus. Funding National Institute for Health Research Health Technology Assessment programme.

Routine pulse oximetry aided detection of 5/27 of critical and 5/50 of serious anomalies in this sample, but did not prevent five babies with critical and 15 with serious anomalies being discharged undiagnosed. Results from screening over 250 000 babies have now been published, but this total includes only 49 babies with transposition, and even smaller numbers of rarer anomalies.

BackgroundThe relationship between type 1 diabetes and epilepsy in the paediatric population is unclear. There is evidence to suggest that antibodies to glutamic acid decarboxylase, an auto-antigen implicated in type 1 diabetes, are also associated with the development of epilepsy. However, seizures occurring in children with diabetes may be attributed to hypoglycaemia rather than an underlying seizure disorder.ObjectivesTo identify the number of children with both type 1 diabetes and epilepsy in the region, and to elucidate associated management issues.MethodsA data collection form was designed following a literature search. Paediatric consultants and nurse specialists caring for children with diabetes in the Northern Deanery were contacted to identify patients who might also have epilepsy. Information was then collected from case notes by two reviewers and analysed using Microsoft Excel.ResultsData from 10 regional hospital clinics was reviewed: 16 children out of 1258 seen in diabetic clinics were being managed for both conditions (1.3%). Of the 12 sets of notes accessed (75% ascertainment), there was an equal sex distribution. In six patients diabetes was diagnosed before epilepsy (50%). Six children had at least one documented hypoglycaemic seizure (50%). Three children had a family history of diabetes (25%), and three children had a family history of epilepsy (25%). One child had a family history of both diabetes and epilepsy (8%). Three children had positive pancreatic islet cell antibodies (25%), one had positive anti-GAD antibodies (8%), one child had primary hypothyroidism (8%) and one had coexisting coeliac disease (8%). Diabetic control was thought to be good in two patients (17%); six patients achieved good seizure control (50%). Five children had special educational needs (42%), three of whom had poorly controlled epilepsy and diabetes.ConclusionThere is no evidence that epilepsy occurs more frequently in our regional population of children with type 1 diabetes; however, the numbers are small and a more comprehensive national prospective study may be indicated. From a practical perspective, it should not be assumed that seizures—with or without low associated low blood glucose levels—are due to diabetes in isolation, as this may delay the diagnosis of coexisting epilepsy.

Aim Urinary tract infection (UTI) is a common bacterial infection in children. Much controversy exists over the level of investigation required for UTI, looking for evidence of scarring and vesicoureteric reflux (VUR). In the Northern Region we follow local guidelines which involve imaging, prophylaxis and prolonged follow-up for all those with first UTI under 1 year of age. This places a heavy burden on NHS resources. NICE produced new guidelines in 2007 which results in fewer investigations being recommended in a more targeted fashion. Our aim is to identify how many episodes of VUR we would have missed had we been following NICE guidelines. Methods A retrospective study in a large district general hospital from January 1998 - April 2008, looking at all children <1 year of age who had an MCUG investigation for UTI. Notes for all with abnormal scans were reviewed to determine if they met the criteria for scan under NICE. We could then identify patients with VUR who would have been missed if we followed NICE. Results Over a period of 10 years, 368 MCUGs were done for UTI in children under 1 year, of these, 73 (19.8%) were reported abnormal. Applying NICE guidelines retrospectively, 15 of these 73 would have been recommended by NICE, 58 were therefore performed in our study that went against the NICE guidelines, all of which were abnormal to some degree. Most showed evidence of grade I or II VUR but 9 showed evidence of grade III or VI reflux. Conclusion In rationalising investigation of UTI according to NICE guidelines we would have missed 58 children with a diagnosis of VUR. Many of these have grade I or II reflux, the clinical significance of which is unclear. However there are 9 children in our cohort with Grade III or IV VUR who would have been missed. Controversy continues to remain as to whether or not the presence of primary VUR predicts renal scarring and damage but some paediatric nephrologists continue to believe there to be a causative effect between the two.