SEIZURES IN

CHILDHOOD
BY
Dr. Mohamed Abdulhay Ahmed
Lecturer of pediatrics and pediatric neurology
Faculty of medicine – Helwan University
■ You are working an ER shift in your pediatric rotation. A 1 year old male is brought into the
Emergency Department being carried by his father. He started seizing approximately 10 minutes
ago. You noticed that during the seizure the patient was unconscious and his hands clenched and
both upper arms and both lower legs trembled like when people are shivering. The eyes glared
upward, and there was foam coming out from the patient’s mouth .
■ The patient’s father confessed before the seizure the patient has been ill with a high fever , a slight
cough and mild nasal congestion since approximately 1 day before entering the hospital . There
is no vomiting, diarrhea, rash, or fussiness.
■ Past medical history is unremarkable.
■ Family history is significant for an uncle who has epilepsy.
■ Exam: T 39.8 degrees C ,P 165, RR 30, BP 90/60, O2 sat 100% on RA. He is alert to his
surroundings. Nasopharyngitis is noticed. Skin is without bruising or neurocutaneous stigmata.
Respirations are regular. Pupils are equal and reactive. The Brudzinski and Kernig signs are
difficult to assess. Neurologically, he moves both arms and legs equally. His tone appears normal.
The rest of the examination is normal.
 Seizure(Convulsion)

Definition
■ A seizure is a transient occurrence of signs and ̸ or symptoms resulting from abnormal
excessive neuronal activity in the brain.
■ It can be characterized by any of the following;
➢ Abnormal motor activity(convulsion)
➢ Abnormal sensation
➢ Abnormal behavior
➢ Abnormal autonomic function
Characteristics
■ Abrupt onset and abrupt offset
■ Time limited
■ A change in motor activity and/or consciousness
■ A post-ictal period of decreased responsiveness, usually follows most seizures.
■ If it recurs, usually will be of the same picture(stereotypic)
Q2: What is the likely differential diagnosis for such a case?

“Let`s see”
1) Febrile convulsions(FC)
 Febrile convulsions(FC)
FC are the most common type of seizures in childhood
Definition;
■ Febrile seizures are seizures that occur between the ages of 6 and 60 mo (peak 12-18 mo) with a
temperature of 38°C (100.4°F) or higher, that are not the result of CNS infection and that occur in
the absence of a history of prior afebrile seizures.
Epidemiology;
■ Between 2% and 5% of neurologically healthy infants and children experience at least one,
usually simple, febrile seizure.
■ Febrile seizures recur in approximately 30% of those experiencing a first episode, in 50% after
two or more episodes. Several factors affect the recurrence risk (see Table ).
■ only 5% (range 1–33%, dependent on risk factors) of children who experience febrile seizures
proceed to develop epilepsy later in life. There are several predictors of epilepsy after febrile
seizures (see Table).
Types of FC; (https://www.youtube.com/watch?v=i0AfWVe7CvY)
■ A simple febrile seizure is a primary generalized, usually tonic-clonic, attack associated with
fever, lasting for a maximum of 15 min, and not recurrent within a 24-hr period.
■ A complex febrile seizure is more prolonged (>15 min), and/or is focal, and/or recurs within 24
hr.
Pathophysiology of FC;
■ The condition is presumed to be due to multifactorial inheritance. This is supported by presence
of a positive family history for febrile seizures in many patients, as well as detection of multiple
single genes that cause the disorder in such families
■ Genes associated with febrile seizures include SCN1A, SCN1B, SCN9A, and CPA6. In terms of
other etiologies, a dysregulation between the proinflammatory IL-6, and IL-8 cytokines and
antiinflammatory ILR- 1A cytokines has been associated with FC.
NB) Febrile seizures often occur in the context of otitis media; roseola (human herpesvirus (HHV) 6)
infections.
Evaluation;
The following figure delineates the general approach to the patient with febrile seizures.
Investigation studies;
■ Lumbar Puncture
o Meningitis should be considered in the differential diagnosis, and lumbar puncture should be performed for all
infants younger than 18 mo of age who present with fever and seizure.
o A lumbar puncture is an option in a child 6-18 mo of age who is deficient in Haemophilus influenzae type b and
Streptococcus pneumoniae immunizations or for whom the immunization status is unknown.
o It should be done at any age if there are clinical signs or symptoms of concern.
o If LP is decided, please do CT scan first to exclude signs of raised intracranial pressure.

■ EEG
o EEG need not be performed as part of the evaluation.
o An EEG would not predict the future recurrence of febrile seizures or epilepsy even if the result is abnormal.
o An EEG should, therefore, generally be restricted to special cases in which epilepsy is highly suspected (see
before), and, generally, it should be used to delineate the type of epilepsy rather than to predict its occurrence.
o If an EEG is indicated, it should be delayed until or repeated after more than 2 wk have passed.
■ Blood Studies
o Blood studies (serum electrolytes, calcium, phosphorus, magnesium, and a complete blood count)
are not routinely recommended in the workup of a child with a FC ,unless clinically indicated.
o For example, Blood glucose should be measured initially and with prolonged postictal
obtundation or with poor oral intake (prolonged fasting). Serum electrolyte should be
performed if clinically indicated e.g dehydration.
■ Neuroimaging
o A CT or MRI is not recommended in evaluating the child after a first simple febrile seizure.
o It is recommended for children with complex febrile seizures, particularly if the child is
neurologically abnormal.
Management of FC;
A)Immediate management;
✓ Emergency resuscitation(A,B,C)
✓ Termination of the attack;
If the seizure lasts for longer than 5 min, acute treatment with midazolam, or diazepam is needed.
Alternatively, buccal or intranasal midazolam may be used
✓ Lower the body temperature;
Antipyretics can decrease the discomfort of the child but do not reduce the risk of having a recurrent
febrile seizure.
✓ Treat the cause of fever accordingly e.g. antibiotics for acute tonsillitis
B)Long-term management;
✓ Intermittent prophylaxis; In cases of frequently recurring febrile seizures i.e Interval less than 3
months between attacks, intermittent oral clonazepam (0.01 mg/kg every 8-12 hr up to a maximum
dose of 1.5 mg/day) or oral diazepam (0.33 mg/kg every 8 hr) can be given during febrile illnesses.
Such therapies help reduce, but do not eliminate, the risks of recurrence of febrile seizures.
✓ Continuous prophylaxis; with the AEDs phenobarbital or valproic acid may be considered for children
with a high risk for later epilepsy
2) CNS infection
 CNS infection
Infection of the CNS may be

1.Diffuse e.g
➢ Meningitis; may be caused by bacterial, viral, fungal or rarely by other
organisms e.g TB
➢ Encephalitis; most probably caused by viral infection.

2.Focal(mainly bacterial) e.g

➢ Brain abcess
➢ Subdural empyema

NB)The diffuse CNS infection is commonly presented by encephalopathy ,

whereas the focal infection is commonly presented with focal neurological
deficits.
 Meningitis
1)Acute bacterial meningitis
✓ Causes;
■ Newborn; E.coli, GBS and listeria
■ Infants and older children; Hemophilus influenza type b, Strept. Pneumoni
and meningiococci(most common)
✓ Clinical Picture of bacterial meningitis;
• Before 3 months : nonspecific symptoms including
1) hyperthermia or hypothermia,
2) Signs of meningeal irritation ; minimal and may include poor
feeding ,irritability or lethargy
3) Signs of increased intracranial pressure(particularly in late
onset meningitis) e.g Bulging anterior fontanel +/- cushing triade in in
sever cases
4)Other neurological signs(mostly in sever complicated cases) e.g
convulsions, rapid deterioration in sensorium and cranial nerves palsy
– After age 3 months, the child may display the classic signs of
bacterial meningitis i.e.
1. fever
2. signs of increased intracranial tension; Headache, projectile
vomiting and blurring of vision +/- cushing triade in in sever
cases
3. signs of meningism; Neck stifness (Guarding rigidity
hyperextension),Kernig´s sign and Brudziniski´s sign
4. Other neurological signs(mostly in sever complicated cases) e.g
convulsions, rapid deterioration in sensorium and cranial nerves
palsy
 ✓ Complications of acute bacterial meningitis;
1) Early;
■ SIADH
■ Brain abcess or subdural empyema
■ Vasculitis
■ Shock due to acute adrenal insufficiency(Meningiococcemia)
■ Purpura fulminans(meningiococcemia)
■ DIC
■ Metastatic complications e.g arthritis, pericarditis ,empyema,etc….
2) Late;
■ Paralysis
■ Epilepsy
■ MR
■ Hydrocephalus
 Aseptic meningitis
✓ Causes;
1)Infections;
■ Mostly viral e.g enteroviruses, varicella, mumps and rubella.
■ Other infections e.g mycoplasma & chlamydia, Fungi(cryptococcus and candida),TB and
protozoa(Toxoplasmosis)
2) Allergic reaction following vaccinations e.g after influenza vaccine
3) Allergic reaction following drug administration e.g IVIG
4)Malignancies e.g leukemia
5)Miscellaneous e.g lead poisoning
✓ Clinical Picture of aseptic meningitis
• As septic meningitis + Evidence of underlying cause e,g rash in case of ECHO virus
 ✓ Diagnosis of meningitis
Diagnosis depends mainly on the presence of clinical signs and confirmed by
CSF analysis
■ CT brain; in all patients suspected with meningitis before LP to search for
evidence of elevated intracerebral pressure (ICP), obstructive
hydrocephalus, or mass effect e.g brain abcess and subdural empyema.
■ Lumbar Puncture(mainly);
https://www.pedscases.com/classic-video-approach-lumbar-punctures
CSF sample should be sent to the clinical pathology laboratory for
biochemical, cytological and to the bacteriology lab. for Gram stained film,
Zeiehl-Nelsen stain, direct examination and cultures
Normal CSF Septic meningitis Aseptic meningitis
- Aspect Clear Turbid Clear except in TB
meningitis
- Glucose ≥ 2/3 of s.glucose ≥ 100 Usually Normal
- Proteins 20 – 40 mg/dl ,usually ≥ 100 Slightly (50 –
100)
- WBC ≤ 5, all ,usually ≥ 100 ,usually ≥
mononuclears mostly PMN 20(early may be
 • CBC & Blood culture(particularly in case of neonatal meningitis)
Treatment of Meningitis
1)Supportive treatment
■ Isolation of the patient in a separate room
■ Immediate stabilization and support of the critically ill (airway,
breathing, circulation).
■ Measures to reduce increased intracranial tension(If needed)e.g CSF
drain, hyperosmolar therapy or decompressive craniectomy in sever
persistent cases
■ Control of fever by antipyretic
■ Control of seizures by diazepam, phenobarbitone or phenytoin.
■ IV dexamethazone 0.15 mg/kg every six hours for a short period early in
the disease, under good cover of antibiotics, may reduce the incidence of
some complications e.g deafness and septic shock.
 2)Definitive treatment;
■ In bacterial meningitis; give IV antibiotics initially before results of CSF
culture(based on the common etiologies) as following
✓ Infants younger 2months, ampicillin in a dose of 200 mg/kg/d in 4 divided doses and
an aminoglycoside(gentamycin) in a dose of 7.5 mg/kg/d in 3 divided doses or a
cephalosporin (cefotaxime) in a dose of 200 mg/kg/d in 4 divided doses .
✓ Children >2 months, IV ampicillin In a dose of 300 mg/kg/d in 4 divided doses and a
cephalosporin (ceftriaxone in a dose of 100 mg/kg/d in 2 divided doses or cefotaxime
in a dose of 200 mg/kg/d in 4 divided doses) can be used. Since S pneumoniae
occasionally occurs in this age range, vancomycin should be considered instead of
ampicillin in a dose of 60 mg/kg/d in 4 divided doses.
NB)Treatment should be continued for at least 10-14 days(In newborn for 3 wk) or until
afebrile for five full days(In newborn for 2 Wk).
■ In aseptic meningitis
✓ Patients with signs and symptoms of herpetic meningoencephalitis should receive
acyclovir at a dose of 10mg/kg every 8 hours IV for 14 days.
✓ Patients with signs and symptoms of fungal meningitis should receive IV
amphotericin B (0.3-0.5 mg/kg/d) combined with oral flucytosine(150 mg/kg/d) in
 Encephalitis
✓ Causes;
1)Viral Infections e.g enteroviruses, varicella
2)Allergic reaction following infections (ADEM)
3) Allergic reaction following vaccinations e.g after
influenza,pertussis,rabies,etc….
✓ Clinical Picture of encephalitis
Usually triade of;
o Low grade fever
o Encephalopathy i.e Behavioral and personality changes, decreased level of
consciousness or Generalized or localized seizures
o neurological deficits e.g
✓ Flaccid paralysis
✓ Others according to site of involvement;

Hemiplegia,
Ataxia,
Basal ganglia causing rigidity and abnormal movements.

Diagnosis of encephalitis
Is both clinical and laboratory
Neuroimaging
■ CT brain with and without contrast agent, in all patients with encephalitis before
LP to search for evidence of elevated intracerebral pressure (ICP)
■ MRI is more likely to show abnormalities earlier in disease course than head CT
particularly in cases with herpes encephalitis. MRI may show several foci of
increased T2 signal intensity in medial temporal lobes and inferior frontal gray
matter.
■ LP findings are like those of aseptic meningitis
EEG:
■ In HSE, characteristic paroxysmal lateral epileptiform discharges (PLEDs)
every 1-3 seconds and the low amplitude over one or more regions
esp.over temporal lobe.
Additional work up
➢ Neurometabolic diseases e.g MELAS should be excluded esp. in
recurrent encephalitis like picture; Perform blood sugar, serum ammonia
and serum lactate, and in selected cases, TMS and urine organic acid.
✓ Treatment of encephalitis;
Like that of aseptic meningitis
3)Epilepsy
■ Less than 1/3 of seizures in children are caused by epilepsy.
■ It is usually triggered in the absence of external provoking factors
■ epilepsy is considered present when two or more unprovoked seizures occur in a time frame of longer than
24 hr.
■ Etiology;
A)Genetic(Idiopathic); 80% the etiology is not determined.
o These cases present without clinical neurological and/or neuro-radiological signs.
o Particularly in patients with specific epilepsy syndromes or with Family history of similar condition
B)Structural (symptomatic);20%
o In these cases, there are lesions that produce clinical neurological and/or neuro-radiological signs.
o They could be;
❖ Prenatal;
✓ Brain malformations
✓ TORCHS
❖ Perinatal;
✓ Infection e.g neonatal sepsis
✓ HIE
✓ Birth trauma
❖ Postnatal;
✓ CNS infection
✓ Head trauma
✓ Cerebrovascular stroke
✓ Hypoxia e.g cardiac arrest or near drowning
✓ Brain tumours
✓ Immune-mediated e.g autoimmune encephalitis
✓ Neurometabolic disorders
✓ Neurodegenerative disorders
✓ Neurocutaneous syndromes
▪ Clinical (descriptive) classification of epileptic
seizures
1)Generalized seizures
1)Tonic-clonic seizures(Grand mal)
■ Preictal: aura e.g. headache or flashes of light
■ Ictal(See video; https://www.youtube.com/watch?v=zEmTQhlHfFc)
o Sudden loss of consciousness and falling.
o Tonic phase
With loss of consciousness, limbs are extended, eyes are rolled up and the head is thrown backward
or to one side. Cyanosis of the face, biting the tongue and cessation of respiration occur
o Clonic phase
Respiration returns, with repetitive contraction and relaxation of all muscles. Salivation and
micturition may occur during this phase It lasts for few minutes.
▪ Postictal: deep sleep for hours
■ Etiology: symptomatic (2ry) or idiopathic.
2)Absence(petit mal)
■ Absence seizures are generalized seizures consisting of attacks of staring, unresponsiveness, and
eye flutter lasting usually for a few seconds, that followed by continuation of the original activity
as if nothing happened.
■ The attacks can be triggered if the child over breaths(hyperventilation) for a minute or two. (See
video; https://www.youtube.com/watch?v=UACyepoANVA)
■ Postictal: no postictal manifestations
■ EEG : characteristic EEG finding: 3 spike / second wave precipitated by hyperventilation
■ Etiology: idiopathic or genetic
3)Myoclonic seizures
■ They take the form of sudden shock-like jerks affecting one part or the whole of the body. They
may be predominantly flexor or extensor. (See video;
https://www.youtube.com/watch?v=s8JrRuWfHOw)
■ Myoclonic seizures can be distinguished from clonic seizures by the rapidity of the jerks (<50
msec) and by their lack of rhythmicity.
■ Etiology: mainly symptomatic (2ndry) or idiopathic.
4) Epileptic spasms (formerly Infantile Spasms)
▪ These are seen only in infants as they ususlly start between age of 3-8 months.
■ The spasms consist of sudden flexion or extension of the neck and limbs lasting only for few
seconds ,but they usually occur in clusters lasting 15-30 minutes several times per day.(See
video; https://www.youtube.com/watch?v=vHpeTLrNQjg)
■ More than 50% of cases have underlying disorder.
■ EEG is diagnostic: hypsarrythmia
5)Atonic seizure
■ These attacks start usually by increase in muscle tone or brief myoclonic jerks followed by loss of
postural tone and falling to the ground. (See video;
https://www.youtube.com/watch?v=EEusUYl5uQ4)
 2)Focal(partial) seizures
1)Simple partial(Focal Seizures With Preserved Awareness)
■ Attacks consist of twitching or jerking of one side of the face, one arm or one leg, without
impairment of consciousness.
■ A simple partial seizure may proceed to a GTC seizure with loss of consciousness(partial with
secondary generalization). (See video; https://www.youtube.com/watch?v=3PfNbepI3fI)
2)Complex partial(Focal Seizures With Impaired Awareness)
■ These seizures usually last 1-2 min and are often preceded by an aura, such as a sense of fear,
visual hallucinations or strange sensations .Children younger than 7 yr old are less likely than
older children to report auras, but parents might observe unusual preictal behaviors that suggest
the experiencing of auras.
■ Subsequent manifestations consist of decreased responsiveness, staring, and automatisms.
Automatisms are commonly automatic semipurposeful movements of the mouth (oral,
alimentary such as chewing) or to a lesser extent of the extremities (such as manipulating the
sheets; leg automatisms such as shuffling, walking). (See video;
https://www.youtube.com/watch?v=Fa_w_Et9Jqg)
4) Other causes
■ Traumatic(head trauma with subsequent concussion or Hge).
■ Toxic(Exogenous e.g drug intoxication aminophylline, poisoning lead poisoning
/or, Endogenous e.g Uremia, hepatic failure and DKA)
■ Hypoxic e.g near drowning, shock or cardiac arrest
■ Vascular e.g hypertensive encephalopathy or stroke
■ Metabolic(hypoglycemia, electrolytes disturbances e.g hypocalcemia, hypomagnesemia,
hypo or hypernatremia, or IEM)
Now
Q3: what pt information on history & examination do you want to gather from the parents while you
are managing a case of seizure?
■ History
1. Did the child have a seizure before?
2. Character of Seizures:
- Type (tonic, clonic, absence, myoclonic)
- Distribution (focal or generalized)
- Triggers: head trauma, fever.
- Duration (brief or prolonged)
3. Etiology of seizures
- Manifestations of CNS infection (fever, vomiting, loss of consciousness)
- History of trauma
- Developmental regression degenerative brain disorders
- Encephalopathy, failure to thrive inborn errors of metabolism
4. Treatment history (prior anticonvulsant medication and the child’s response)
■ Examination (directed to search for organic cause)
General
1. Vital signs: blood pressure temperature
2. Measurements: head circumference: microcephaly with congenital infections
3. Trunk and limbs: skin lesions in neurocutaneous syndromes e.g. cafe au lait patches
Systems
1. Neurological examination
Level of consciousness
Signs of increased intracranial pressure
Signs of meningeal irritation.
Signs of lateralization
Motor, Reflexes, sensations and cranial nerves examination.
Fundus examination : papilledema with increased intracranial tension
2. Abdominal examination: organomegaly may suggest metabolic or storage disorders
Q4:From your point of view, What investigations would be most helpful and why in a case of
seizure?
Laboratory
1. Blood picture.
2. Blood chemistry: serum electrolytes(Na – Ca – Mg – P), KFT(urea & creatinine), LFT(AST &
ALT), Fasting plasma glucose and urine toxicology.
3. CSF analysis if CNS infection is suspected.
4. Screening for inborn errors of metabolism(Aminogram and TMS),if clinically suspected
5. TORCH screening, if clinically indicated (microcephaly, recurrent seizures, cataract),
Imaging
1. EEG
It is done usually, if epilepsy is clinically diagnosed(during wakefulness and during normal or
induced sleep ), as well as with activation procedures as hyperventilation & photic stimulation.
2. CT and MRI if intra-cranial lesion is suspected (increased tension or focal deficit)
Q6)What are the lines of treatment that you should follow in managing of a case of seizure?
A)Immediate management(treatment of the ongoing seizure)
■ First aid measures: A,B,C
1. A: open the airway
2. B: Breathing support and oxygen therapy
3. C: insert IV line
▪ Check blood glucose
▪ Immediate anticonvulsant drugs to stop convulsions
1. Diazepam 0.5 mg/kg slow IV or rectal: may repeat dose once
Or
Midazolam 0.15mg/kg IV ; may repeat dose once, but if no available IV access, buccal or intranasal midazolam solution with atomizer could be given
2.
Phenobarbitone 15 -20 mg/kg slow IV (loading dose)
Phenytoin: 15-20 mg/kg slow IV (loading dose)
Levitiracetam; 25 – 50 mg/kg slow IV (loading dose)
Valproate ;20 – 40 mg/kg slowly IV(Loading)
NB)give another anticonvlsant rather than that used if convulsion not controlled
3. If not controlled, transfer to ICU
✓ First line: midazolam constant infusion.
✓ Second line anticonvulsants (thiopental )
NB)Usually this requires mechanical ventilation to insure adequate oxygenation and ventilation.
B)Long term management;
➢ In case of occasional symptomatic seizures; treat the underlying cause accordingly
➢ In case of epilepsy; give antiepileptic medications
✓ Rules in long term antiepileptic therapy
1. Choice of drugs according to clinical and EEG findings.
2. Number of drugs: start with one drug (monotherapy) in small dose (to avoid toxicity,
improve compliance and reduce the cost). A second drug is added (polytherapy) if the first
drug failed to control seizures.
3. Dose: start with an average dose and gradual increase till seizure control.
4. Duration of therapy: at least 2or 3 years after the child being seizure free
5. Termination of therapy: very gradual (status epilepticus usually develops with sudden
termination)
 Antiepileptic drugs

✓ Parent counseling
Children with idiopathic epilepsy should
1. Attend regular schools.
2. Avoid watching TV except in lighted room and far enough from the screen.
3.Computer games and swimming should be done under supervision
Q5: Finally,Could you suggest a work up algorithm for a case of seizure

1)Occasional(acute symptomatic or provoked)seizures

■ They are not a single disease but due to multiple causes.
■ They occur occasionally.
■ They are usually originating from disorders outside the brain, either with fever or without a fever;
A)With fever:
■ Febrile convulsions(see later)
■ CNS infections
B)Without fever:
■ Traumatic(head trauma with subsequent concussion or Hge).
■ Toxic(Exogenous e.g drug intoxication aminophylline, poisoning lead poisoning /or, Endogenous
e.g Uremia, hepatic failure and DKA)
■ Hypoxic e.g near drowning, shock or cardiac arrest
■ Vascular e.g hypertensive encephalopathy or stroke
■ Metabolic(hypoglycemia, electrolytes disturbances e.g hypocalcemia, hypomagnesemia, hypo or
hypernatremia, or IEM)
2)Epilepsy(Chronic or recurrent unprovoked seizures)
■ Less than 1/3 of seizures in children are caused by epilepsy.
■ It is usually triggered from within the brain in the absence of external provoking factors
■ epilepsy is considered present when two or more unprovoked seizures occur in a time frame of longer than
24 hr.
■ Etiology;
A)Genetic(Idiopathic); 80% the etiology is not determined.
o These cases present without clinical neurological and/or neuro-radiological signs.
o Particularly in patients with specific epilepsy syndromes or with Family history of similar condition
B)Structural (symptomatic);20%
o In these cases, there are lesions that produce clinical neurological and/or neuro-radiological signs.
o They could be;
❖ Prenatal;
✓ Brain malformations
✓ TORCHS
❖ Perinatal;
✓ Infection e.g neonatal sepsis
✓ HIE
✓ Birth trauma
❖ Postnatal;
✓ CNS infection
✓ Head trauma
✓ Cerebrovascular stroke
✓ Hypoxia e.g cardiac arrest or near drowning
✓ Brain tumours
✓ Immune-mediated e.g autoimmune encephalitis
✓ Neurometabolic disorders
✓ Neurodegenerative disorders
✓ Neurocutaneous syndromes