Children who present with altered mental status or possible seizures could be suffering from one of a number of causes. While EEG could help sort through that extensive differential, the practical barriers to EEG use in the emergency department or the PICU for diagnosticians to rely on indirect assessments. Fortunately, new technology is now available that allows EEG to be deployed rapidly and accurately in children and adolescents.
EEG indications in children—The unmet need for pediatric EEG
While febrile seizures are the most common neurological disorder in children. For most young children, the course of febrile seizures is benign, and the prognosis is favorable. Indeed, routine EEG is not even needed for most cases of febrile seizures. Unfortunately, the benign nature of febrile seizures has led many healthcare professionals to overlook the many instances in which EEG should be ordered in children.
Febrile Status Epilepticus
Most notable of these, perhaps, is febrile status epilepticus, which are febrile seizures lasting for more than five minutes.1 In a study of 119 children with febrile status epilepticus the median duration of the event was 68 minutes; about half were continuous, and half intermittent; and in three-quarters of children in the group, febrile status epilepticus was their first seizure event.2 Prolonged seizures in children, even febrile seizures, require accurate diagnosis and urgent treatment to interrupt the event.
Non-febrile status Epilepticus
Despite the presence of fever, status epilepticus due to specific causes such as acute meningitis are not a form of febrile status epilepticus. About one in five cases of children with fever and status epilepticus is due to a cause other than febrile seizure.2 CSF analysis can help differentiate certain causes of non-febrile status epilepticus such as bacterial meningitis; however, some acute encephalopathies that cause seizures result in completely normal CSF and brain MRI findings.3 Thus, EEG has a place in the diagnosis and management of all prolonged seizure states in children.
Non-convulsive seizures and non-convulsive status epilepticus are an increasingly recognized cause of altered mental status, especially in critically ill patients.(1,4) While more than half of patients with these events have a history of seizure or epilepsy, nearly half do not. Absence status epilepticus is primarily diagnosed in children, but all other forms of non-convulsive seizures are possible on children including focal and generalized seizures. Indeed, non-convulsive status epilepticus may follow a convulsive status epilepticus that was inadequately treated. Regardless of etiology, non-convulsive seizure activity is, by nature, difficult to diagnose clinically. Accurate diagnosis requires EEG.
Head trauma, metabolic disruption, or toxin exposure
A strong case for pediatric EEG can be made in any case of a child with altered mental status of unknown cause. EEG may reveal the degree5 and etiology6 of encephalopathy. Pediatric EEG can be used to workup persistent confusion or decreased responsiveness in many contexts. Indeed, if pediatric EEG were practical, it would be used frequently in acute and tertiary care settings.
The Challenges of Rapidly Obtaining EEG in Children
As anyone who has worked in an emergency department or PICU knows, obtaining an EEG is a logistical hassle. The site must have a portable EEG system, or, more often, the critically ill patient must be moved to an EEG suite. The latter takes the patient away from the urgent care support they usually need in this state. Trained EEG technicians must properly place scalp adhesive electrode pads and electrodes, applying gel to each electrode. This setup process takes considerable time, especially in an urgent or emergent setting where each second spent on diagnosis may be a second not spent on definitive treatment (e.g., non-convulsive status epilepticus). If the patient is experiencing altered mental status, the electrode application process takes even longer as the patient may struggle with the technician.
All of these struggles are an order of magnitude more difficult in children. Often adult EEG equipment needs to be “improvised” to fit the child. Electrodes cannot overlap, so placement is even more difficult on a smaller scalp. Even under ideal circumstances, children tend to struggle against medical professionals attempting to perform tests. With a blood draw or NG-tube placement, the process is quick. In standard pediatric EEG, each electrode becomes its own struggle.
Pediatric EEG in the time of COVID
COVID-19 has created a particularly difficult barrier for healthcare professionals who must use reusable equipment, such as EEG electrodes. SARS-CoV-2 RNA can be found widely distributed on various surfaces and equipment.7 Standard EEG electrodes must be cleaned and disinfected between uses to avoid transmitting diseases from one patient to another. Thus, pediatric EEG faces yet another barrier in the time of COVID, since healthcare professionals must weigh the risk of infection from reusing potentially contaminated EEG equipment.
Pediatric NeuroCap™ overcomes the hurdles to Pediatric EEG
The Pediatric NeuroCap™ is an innovative solution that brings EEG to the modern hospital setting. Brain Scientific adapted its successful NeuroCap™ for adults to be used in children. The cap, which comes in two sizes (Size XS, 43-49 cm; Size S, 47-53 cm), has 22 integrated, pre-gelled electrodes located in accordance with 10-20 international system. The Pediatric NeuroCap™ is as easy to use as the adult version; any member of the clinical team can properly place the cap on a child’s scalp in less than 5 minutes. Because the integrated electrodes are properly aligned once the cap is placed, setup is practically as easy as putting on a hat and affixing the Velcro straps. Once it is placed, it can withstand the child’s movement and tugging delivering up to 4 hours of hospital-grade EEG.
The Pediatric NeuroCap™ is also designed and priced to be disposable. So once one child has had an EEG, pediatric NeuroCap™ can be removed in less than 1 minute and is discarded. This eliminates the risk of infectious disease transmission from reusing equipment.
Pediatric EEG can now be Routine
The ease of use and versatility of the Pediatric NeuroCap™ cannot be overstated. For the first time, healthcare professionals can rapidly obtain hospital-grade EEG data on children and adolescents right in the ED or PICU. Any clinical staff member can apply the cap and start recording in just a few minutes.
Of course, the Pediatric NeuroCap™ requires an amplifier just like the adult device. The Pediatric NeuroCap™ can be used with Brain Scientific’s companion amplifier NeuroEEG or any third-party amplifier—the reusable cable adapter is broadly compatible.
The detection and management of non-convulsive status epilepticus, both febrile and non-febrile, is likely to improve dramatically now that there is a practical means of obtaining EEGs in children. EEG use will not be stopped during pandemics like COVID-19 or any that come in the future because now there is a pediatric EEG headset that is portable and disposable.
1. Trinka E, Cock H, Hesdorffer D, et al. A definition and classification of status epilepticus–Report of the ILAE Task Force on Classification of Status Epilepticus. Epilepsia. 2015;56(10):1515-1523. 10.1111/epi.13121
2. Shinnar S, Hesdorffer DC, Nordli DR, Jr., et al. Phenomenology of prolonged febrile seizures: results of the FEBSTAT study. Neurology. 2008;71(3):170-176. 10.1212/01.wnl.0000310774.01185.97
3. Takanashi J. Two newly proposed infectious encephalitis/encephalopathy syndromes. Brain Dev. 2009;31(7):521-528. 10.1016/j.braindev.2009.02.012
4. Schmitt SE. Utility of Clinical Features for the Diagnosis of Seizures in the Intensive Care Unit. J Clin Neurophysiol. 2017;34(2):158-161. 10.1097/WNP.0000000000000335
5. Kaplan PW. The EEG in metabolic encephalopathy and coma. J Clin Neurophysiol. 2004;21(5):307-318.
6. Kaplan PW, Rossetti AO. EEG patterns and imaging correlations in encephalopathy: encephalopathy part II. J Clin Neurophysiol. 2011;28(3):233-251. 10.1097/WNP.0b013e31821c33a0
7. Guo ZD, Wang ZY, Zhang SF, et al. Aerosol and Surface Distribution of Severe Acute Respiratory Syndrome Coronavirus 2 in Hospital Wards, Wuhan, China, 2020. Emerg Infect Dis. 2020;26(7):1583-1591. 10.3201/eid2607.200885