A 16-year-old girl with type 1 diabetes for 10 years attends for transition planning to adult services. Her HbA1c has been consistently between 65-72 mmol/mol over the past 2 years. Annual screening shows persistent microalbuminuria (ACR 4.8 mg/mmol) and background diabetic retinopathy with scattered microaneurysms bilaterally. She is on appropriate therapy including an ACE inhibitor. She asks about her long-term prognosis. What is the most appropriate counselling regarding her microvascular complications?

Optimizing glycaemic control now can still slow progression even with established complications

Microalbuminuria at this stage is irreversible regardless of subsequent glycaemic control

With current control, progression to end-stage renal disease is inevitable within 10 years

Background retinopathy always progresses to proliferative retinopathy requiring laser therapy

Presence of two microvascular complications indicates imminent need for renal transplantation

A 4-year-old boy with newly diagnosed generalized epilepsy is being commenced on sodium valproate. His mother asks about potential side effects. Which of the following monitoring investigations should be performed before starting sodium valproate and at regular intervals during treatment?

Liver function tests, full blood count, and serum ammonia

Full blood count, renal function, and thyroid function tests

Electrocardiogram, liver function tests, and lipid profile

Full blood count, vitamin D levels, and bone density scan

Renal function, serum drug levels, and electroencephalogram

A 13-year-old boy with type 1 diabetes for 7 years presents with intermittent episodes of abdominal bloating, early satiety, nausea, and vomiting, particularly after meals. He reports that vomiting sometimes contains food eaten several hours earlier. His HbA1c is 82 mmol/mol. On examination, he has mild epigastric tenderness and a succussion splash. Screening for coeliac disease is negative. What is the most likely diagnosis?

Gastroparesis secondary to diabetic autonomic neuropathy

Diabetic ketoacidosis with gastric stasis

Superior mesenteric artery syndrome

Helicobacter pylori-associated gastritis

Coeliac disease with false-negative serology

A 10-year-old girl with type 1 diabetes for 5 years uses insulin glargine 18 units once daily at bedtime and insulin aspart before meals. She participates in competitive gymnastics training 5 evenings per week from 5-7pm. Her mother reports that she frequently becomes hypoglycaemic during and after training sessions despite eating extra snacks. Pre-dinner glucose is usually 8-10 mmol/L. What is the most appropriate modification to her insulin regimen?

Reduce the pre-lunch insulin aspart dose by 30-50% on training days

Increase the pre-lunch insulin aspart dose to provide better afternoon glucose control

Switch insulin glargine from bedtime to morning administration

Add metformin to reduce insulin requirements

Split insulin glargine to twice daily administration with reduced total daily dose

A 7-year-old boy with newly diagnosed focal epilepsy is being considered for anti-epileptic drug therapy. His seizures consist of focal motor seizures affecting his right arm with preserved awareness, occurring 2-3 times per week. MRI brain shows a small left frontal cortical dysplasia. His parents are concerned about side effects of medication. Which of the following statements regarding the decision to commence anti-epileptic drug treatment is most accurate?

The presence of a structural brain lesion increases the risk of seizure recurrence and supports starting treatment

Focal seizures with preserved awareness do not require anti-epileptic treatment

Anti-epileptic drugs should be started immediately after a single unprovoked seizure to prevent recurrence

Anti-epileptic drugs are contraindicated in children under 10 years due to neurodevelopmental concerns

Treatment should be delayed until seizures occur daily to confirm the diagnosis

A 15-year-old boy with type 1 diabetes for 9 years attends clinic with his parents. Over the past year, his HbA1c has deteriorated from 58 mmol/mol to 85 mmol/mol. He admits to frequently missing insulin doses and not checking his blood glucose. He expresses frustration about being 'different' from his peers and wanting to be 'normal'. His parents report frequent arguments at home about diabetes management. What is the most appropriate initial approach to address this situation?

Explore the patient's perspective and concerns using motivational interviewing techniques

Arrange immediate referral to child and adolescent mental health services

Initiate continuous glucose monitoring to improve awareness of glucose levels

Inform the parents that they need to resume full responsibility for diabetes management

Switch to insulin pump therapy to simplify the treatment regimen

A 5-year-old girl presents to the emergency department with a 20-minute generalized tonic-clonic seizure that has not responded to two doses of buccal midazolam given by paramedics. Intravenous access is established. Blood glucose is 5.2 mmol/L. What is the most appropriate next immediate management?

Intravenous lorazepam 0.1 mg/kg

Intravenous phenytoin 20 mg/kg infusion

Intramuscular phenobarbital 20 mg/kg

Intravenous levetiracetam 40 mg/kg

Which of the following is the primary mechanism by which the ketogenic diet exerts its anti-epileptic effect in children with drug-resistant epilepsy?

Metabolic shift producing ketone bodies that stabilize neuronal membranes and alter neurotransmitter levels

Reduction in neuronal excitability through GABA receptor upregulation

Inhibition of voltage-gated sodium channels in neuronal membranes

Decreased glutamate synthesis and enhanced glycine-mediated inhibition

Direct antagonism of NMDA receptors reducing excitatory neurotransmission

A 9-year-old boy with type 1 diabetes for 4 years uses a basal-bolus insulin regimen. His parents report that his morning pre-breakfast blood glucose readings are consistently high (12-15 mmol/L), despite having good control during the day. His bedtime readings are usually 6-8 mmol/L. A continuous glucose monitor shows that his glucose drops to 3.2 mmol/L at 2am then rises sharply to 14 mmol/L by 7am. What is the most appropriate adjustment to his insulin regimen?

Decrease the evening long-acting insulin dose

Increase the evening long-acting insulin dose

Add a bedtime snack containing complex carbohydrates

Increase the lunchtime rapid-acting insulin dose

Split the long-acting insulin to twice daily dosing

Epilepsy in children for UKMLA AKT: High-Yield Child Health Lessons

Quick Overview

Epilepsy affects 0.5-1% of children, defined as ≥2 unprovoked seizures >24 hours apart or 1 seizure with high recurrence risk. NICE NG217 provides evidence-based guidance on classification, treatment selection by seizure type, and emergency management. Correct seizure classification determines appropriate antiepileptic drug (AED) choice-misclassification leads to treatment failure or seizure exacerbation.

Core Facts & Concepts

Seizure Classification (ILAE 2017)

Seizure Type	Key Features	First-Line AED
Focal onset	Aware/impaired awareness, motor/non-motor	Carbamazepine or Levetiracetam
Generalised tonic-clonic	Loss of consciousness, tonic then clonic phase	Sodium valproate (males), Lamotrigine or Levetiracetam (females)
Absence	Brief (<10s) staring, abrupt onset/offset	Ethosuximide or Sodium valproate (males)
Myoclonic	Brief muscle jerks, consciousness preserved	Sodium valproate (males), Levetiracetam (females)
Tonic/Atonic	Sudden stiffening or loss of tone	Specialist referral required

Figure 1: EEG showing 3Hz spike-and-wave pattern characteristic of childhood absence epilepsy

💊 Sodium Valproate Restrictions (Pregnancy Prevention Programme)

Contraindicated in females of childbearing potential unless conditions met
Must use ≥1 effective contraception, annual risk acknowledgement form
Teratogenic risk: 10% major congenital malformations, 30-40% neurodevelopmental disorders

📊 Key Numbers

Status epilepticus definition: ≥5 minutes continuous seizure or ≥2 seizures without recovery
Treatment threshold: After 5 minutes of seizure activity
Refer to paediatric neurology: Diagnosis confirmation, treatment failure, <1 year age

Problem-Solving Approach

Status Epilepticus Emergency Protocol

0-5 minutes: ABCDE assessment, high-flow oxygen, check glucose, position safely
5 minutes: Buccal midazolam 0.5mg/kg (max 10mg) OR IV lorazepam 0.1mg/kg (max 4mg)
10 minutes (if continuing): Repeat benzodiazepine (same dose)
15 minutes: Call senior help, prepare IV phenytoin 20mg/kg or IV levetiracetam 40mg/kg
25 minutes: Second-line IV AED, consider ICU transfer

Figure 2: Child receiving buccal midazolam administration between lower gum and cheek

🚩 Red Flags for Urgent Referral

Focal neurological signs post-ictally (>Todd's paresis duration)
Developmental regression or loss of skills
Myoclonic seizures in infancy (consider infantile spasms-hypsarrhythmia on EEG)
Seizures <6 months age (structural/metabolic cause likely)

Rescue Medication (Home Management)

Buccal midazolam: First-line, 0.5mg/kg (1-3 months: 2.5mg; 3-12 months: 2.5mg; 1-5 years: 5mg; 5-10 years: 7.5mg; 10+ years: 10mg)
Give after 5 minutes of seizure, call ambulance if no response in 5 minutes

Analysis Framework

AED Selection Decision Tree

When to Avoid Specific AEDs

AED	AVOID in	Reason
Carbamazepine	Generalised epilepsies, myoclonic/absence	May worsen seizures
Sodium Valproate	Females (unless no alternative)	Teratogenicity, neurodevelopmental risk
Phenytoin	Routine use	Narrow therapeutic index, cosmetic effects
Lamotrigine	Myoclonic seizures	May exacerbate myoclonus

Key Points Summary

✓ Epilepsy diagnosis: ≥2 unprovoked seizures >24h apart; seizure classification determines AED choice

✓ Status epilepticus: Treat after 5 minutes-buccal midazolam 0.5mg/kg or IV lorazepam 0.1mg/kg

✓ Sodium valproate: Most effective for generalised epilepsies but contraindicated in females of childbearing potential (10% teratogenicity)

✓ Focal seizures: Carbamazepine or levetiracetam first-line; never use carbamazepine for generalised epilepsy

✓ Absence seizures: Ethosuximide first-line; brief (<10s) staring with 3Hz spike-wave on EEG

✓ Refer to specialist: All new diagnoses, treatment failure, age <1 year, diagnostic uncertainty

✓ Rescue medication: Buccal midazolam at 5 minutes, call ambulance if no response by 10 minutes total

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