SEIZURES IN CHILDREN

Rashmi Kumar
Prof & Head, Pediatrics
King George Medical University
Lucknow
• Prevalence
• Definition
• Conditions that mimic seizures
• Pathophysiology
• Etiology
• Age wise etiology
• Classification
• Assessment
• Febrile seizures
• Management
SEIZURES

• One of the most common life threatening events in

childhood, more than adults

• Paroxysmal electrical activity in brain -->

motor/sensory/autonomic disturbance with
/without alteration of consciousness

• Convulsion – seizure with motor activity 5%

• Epilepsy – recurrent (2 or more) unprovoked

seizures beyond newborn period 0.5%
Seizures: DDx
Tremors –distal, rhythmic, equal amplitude, no loss of
consciousness
Jitteriness

Breath holding spells –always after crying, sequence of

events important

Syncope – after prolonged standing/emotional upset,

gradual loss of consciousness, slow pulse, pallor, sweating,
improves in supine/head down position

Pseudoseizures – older girl, never hurts herself, bizarre

movements, normal s Prolactin

Detailed sequence of events necessary – HISTORY, HISTORY, HISTORY

Seizures: Pathophysiology:
Sustained partial depolarisation in a group of
neurons -->excitability --> sudden
depolarisation in response to stimuli
-->conduction to surrounding cells, distant
synaptically connected cells & subcortical
neurons -->dissemination -->loss of
consciousness
SEIZURES - ETIOLOGY
1st fit/ recurrent fits
I Symptomatic
• Infectious/ post infectious (including granulomas)
• Anoxic/post anoxic
• Vascular
• Trauma/post traumatic
• Tumour
• Congenital - porencephaly, lissencephaly, agenesis of corpus callosum,
neurocutaneous syndromes
• Degenerative
• Metabolic - hypocalcemia/hypomagnesemia
• hypo/hypernatremia
• hypoglycemia
• pyridoxine deficiency
• Inborn errors
• Drugs/Toxins -aminophylline,antihistamines,steroids,phenothiazines,
• hexachlorophene, strychnine, camphor, INH, tetanus, lead,
• shigella/salmonella
• Acute cerebral edema - Hypertension
• Febrile

II Idiopathic
Newborn 1-6 mths 6m-3 yrs >3 yrs

Birth asphyxia/trauma birth asphyxia Febrile idiopathic

IVH cranial malformations CNS infections
Hypocal/hypoglyc inborn errors
IU infections IU infections
Degenerative
Meningitis metabolic
Tetanus
tumour
Inborn errors other
Kernicterus
Polycythemia
Narcotic withdrawal
CLASSIFICATION OF EPILEPTIC
SEIZURES: ILAE 1981

• I Partial 54%
– Simple - motor/sensory/autonomic 7.7%
– Complex 35.5%
– Partial with secondary generalization 56.4%
• II Generalised 40.4%
– Tonic clonic 69%
– Absence 3%
– Myoclonic 20.5%
– Tonic 4.1%
– Atonic 3.1%
• III Unclassifiable 6% (hospital based study in Mumbai)

• However, same patient can have more than 1 type

• Many patients show a distinct evolution of disease
CLASSIFICATION OF EPILEPTIC
SYNDROMES : ILAE 1989

I Localisation related
• Symptomatic
CLASSIFICATIO
• Cryptogenic N OF EPILEPSY
• Idiopathic STILL EVOLVING
II Generalised
• Idiopathic
• Cryptogenic
– West syndrome
– Lennox Gastaut syndrome
– epilepsy with myoclonic astatic seizures
– epilepsy with myoclonic absences
• Symptomatic
– Non specific
– specific
III Epilepsies undetermined whether focal or generalised
IV Special syndromes
EPILEPSY - SPECIAL TYPES:

GTCS: v common
• Aura  tonic spasm loss of consciousness  fall  clonic
movements
• Rolling of eyeballs/Frothing at mouth/Distortion of face
• Incontinence/ Jerky breathing
• Post ictal sleep
 Absence epilepsy
• 2-4% of childhood idiopathic epilepsy
• Girls 3-7 yrs, normal IQ
• Transient loss of consciousness for few secs
• No loss of tone
• Ppted by hyperventilation -

• Treatment – Ethosuximide, valproate

• May develop GTCS
• EEG - 3/sec spike & wave activity
EPILEPSY - SPECIAL TYPES:

Infantile spasms: Onset in 1st year

• Sudden flexion/extension in series esp on awakening
• Upto 100 times /day
• 60% secondary, 30% cryptogenic
• Treatment - ACTH/steroids/ vigabatrin
• Associated with mental regression
• EEG - hypsarrhythmic
• May develop GTCS

Lennox Gastaut:
• 1-8 yrs,
• tonic/atonic/absence type
• EEG - diffuse 2 Hz spike-waves
• Very difficult to control
EPILEPSY - SPECIAL TYPES:

Psychomotor (Temporal lobe) seizures: Complex partial seizures

with origin in temporal lobe.
• Purposeful but inappropriate acts 'automatisms'
• Associated with behavioral problems
• Difficult to diagnose or treat.

Benign epilepsy with centrotemporal spikes: Partial, idiopathic,

• orofacial/hemifacial, 3-13 yrs, often during sleep. Easy to
control

Myoclonic: heterogenous, multiple causes

Juvenile myoclonic: myoclonic jerks esp after awakening

• EEG - 4-6 Hz polyspike, photosensitivity, GTCS may occur
• Good response to Valproate
FEBRILE SEIZURES:

• 2-4% of children
• 3m - 5 yr age
• Assn with fever due to extracranial infection
• Generalised, Short lasting, only one sz per illness
• No mental/neurological/EEG abnormality
• Typical vs Atypical (complex)
• Focal
• Prolonged
• >1 seizure during illness
• 1/3 have at least 1 recurrence
• 1/6 have multiple recurrences
• Risk of epilepsy:
– Fh/o epilepsy
– Atypical
– Abnormal neurologic/mental status
Febrile Seizures: Management

• Exclude CNS infection

• Control fever
• Look for & treat cause of fever
• Rectal diazepam
• Explain to parents, reassure
• If multiple - intermittent oral diazepam   by
80%
• If high risk for epilepsy  long term
phenobarb/valproate.
Seizures: ASSESSMENT
History:
• 1st seizure/ recurrent seizures
• Fever
• Precipitating factors – diarrhea/ vomiting/ drug/ toxin/ metabolic
• Headache/vomiting/visual loss
• Duration
• Age at onset
• No of attacks
• Frequency /, change in seizure type, last seizure when?
• Exact description
– Aura
– partial/generalised onset
– Loss of consciousness
– Tonic/clonic phase
– Associated events - bed wetting/fall/tongue bite
– Duration
– Post ictal
• Precipitating factors
• Diurnal
• Family history
• Antecedant events - trauma/CNS infection/asphyxia
• Personality change/intellectual deterioration
• Failure to thrive
• Developmental milestones
• Treatment
Seizures: ASSESSMENT

Examination:
• BP
• Head circumference
• Skin lesions
• Facial features
• Organomegaly
• Fundus
• Meningeal signs
• Neurological deficit
• Development
Seizures: Investigations

• If features of CNS infection - CSF examination

• Glucose, Ca, Mg - low yield
• Skull Xray - calcification/  ICT - low yield
• EEG: Always diagnostic during a seizure
• Interictal record : normal in 40-50% of epileptics (spikes/sharp waves &
spikes –slow wave complexes)
  yield with sleep, sleep deprivation, hyperventilation, photic stimulation
• 2-10% normal population may have epileptic changes
• EEG indicated in all cases of epilepsy for:
• -confirmation of diagnosis & syndrome
• -type of seizures - absence vs temporal lobe,
• primary generalised vs secondarily generalised
• -presence of underlying lesion/ idiopathic vs symptomatic
• -follow up
• -before withdrawal of AEDs
• -localisation of focus before surgery
• Video EEG
Seizures: Imaging - CT/MRI

Has revolutionised the management of epilepsy

Indications: focal features on exam, EEG
Features of  ICT
Intractable
However, now indicated in every case with unknown cause
Not necessary in febrile/absence/BETS/ JME etc.
Western studies - 30% abnormal (30-50% of focal)
-only 3% treatable
Indian studies:
Very high prevalence of granuloma like lesions –recent onset
partial seizures in child/young adult
40% abn even after 1st seizure
 indicated in every case
 MCQ
• The following are features of benign
(typical) febrile seizures except:
• They are short lasting
• They are always generalised
• They only occur within 4 hours of fever
onset
• They do not recur in the same febrile
illness
The typical EEG pattern in absence epilepsy
is:
• Intermittent spike and slow waves
• Hypsarrythmia
• Burst suppression
• 3 per second spike and waves
The following is true about absence
epilepsy
• It occurs more commonly in boys
• There is loss of tone
• It is precipitated by hyperventilation
• Imaging is usually abnormal
Definition of epilepsy includes:

• At least 3 seizures
• EEG is abnormal
• Imaging is abnormal
• Beyond neonatal period
The following is true about breath holding
spells:

• It is usually preceded by crying

• Child is always blue
• There is no loss of consciousness
• EEG may show spikes
The following is true about infantile spasms
except:

• They occur in clusters

• They may appear like ‘startling’
• They usually occur during sleep
• They are also called ‘salaam attacks’
West syndrome usually has the following
features except:

• Infantile spasms
• Onset in newborn period
• Hypsarrythmia on EEG
• Psychomotor retardation or regression
Imaging in seizures is not indicated in:

• Generalised tonic clonic seizures

• Absence seizures
• Temporal lobe seizures
• Infantile spasms
Prevention of febrile seizures can be
achieved by:

• Intermittent phenobarb
• Long term phenytoin
• Intermittent diazepam
• Long term carbamazepine
Emergency dose of IV diazepam for seizure
control is:

• 1 mg/kg
• 0.5 mg/kg
• 0.1 mg/kg
• 0.3 mg/kg
Seizures - Management

• I Management of acute attack:

• Calm down
• Head down lateral position
• Prevent hurt
• If does'nt stop convulsing in 3-5 min,
• Inj Diazepam 0.3 mg/kg slow iv bolus
• Maybe repeated after 20 min
• Effect lasts 0.5-3 hrs
• SE- hypotension, respiratory depression, secretions
• or
• Rectal diazepam 0.5 mg/kg dose/ nasal midzolam 0.2
mg/kg/dose
 Domiciliary Mx
• Rectal Diazepam 0.5 mg/kg
• Intranasal midzolam 0.2 mg/kg
Seizures: Status epilepticus:

• Prolonged seizure for >20 min or repeated

seizures without regaining consciousness
• Persistent seizure activity  hypoxia,
hypoglycemia, hyperthermia, cerebral
edema & vasomotor instability
• Life threatening
• Risk of permanent brain damage 
Medical emergency
Mx of Status epilepticus
ICU, monitoring
IV dextrose drip
Oxygen
IV Inj Diazepam 0.3 mg/kg or Lorazepam 0.1 mg/kg (longer action) or
Midzolam (lesser respiratory depression)

Inj phenytoin 15-20 mg/kg iv at a rate of <1mk/kg/min

Inj Phenobarbitone 20 mg/kg iv at a rate of 1 mg/kg/min or IV

Valproate 20 mg/kg as infusion in 50 ml NS over 30 min

Ventilatory support + diazepam/midzolam infusion

`` Thiopental infusion
LONG TERM MANAGEMENT OF
EPILEPSY:

I General advice:
• As normal a life style as possible
• No swimming/cycling on road/driving
• Inform teacher
• First aid
• Seizure dairy
• Regularity
LONG TERM MANAGEMENT OF
EPILEPSY:

Drugs:

• When to start? If 2 or more seizures within a 12 month

period
• Monotherapy:
• Start at lower limit & build up gradually till toxicity/control
• If no effect at maximum dose, taper off while introducing
2nd drug
• 4 first line drugs - Carbamazepine, phenytoin, valproate
and phenobarbitone
• No drug completely safe
• 70% can be controlled
First line AEDs
Carbamazepine:
• Ind: Partial, tonic clonic
• Dose: 10-30 mg/kg/d in 2-3 doses13-18 hrs,
• Adv: Relatively safe, improves cognitive fn.
• SE: Diplopia,drowsiness, giddiness
initially.Hepatitis, skin rash, BM depression, drug
interactions, dystonia, can aggravate minor motor
seizures
First line AEDs
Sodium valproate:
Ind: Broad spectrum
Dose: 20-30 mg/kg/d (upto 80) in 2-3 doses
Half Life; 7-10 hrs
SE: Nausea, vomiting, wt gain, hair loss,
hepatic failure, tremors, platelets, s
ammonia, s carnitine, no correlation
between drug levels & toxicity, levels of
other AEDs
First line AEDs
Phenobarbitone
Ind: Tonic-clonic, partial, febrile
Dose: 3-6 mg/kg/d as single doses
level:10-15 g/ml20-80 hrs
Adv: Cheap, once daily dose
SE: Drowsiness, hyperkinesia, cognitive
impairment ??, rash, rickets
First line AEDs
Diphenylhydantoin:
Ind: Tonic-clonic, atonic, partia
Dose: l4-8 mg/kg/d in 2 doses
level: 10-20 g/ml
Half Life: Upto 20 hrs
SE: Hirsutism, gum hyperplasia, rickets,
ataxia, lymphoma like syndrome, Sle like
illness, megaloblastic anemia, rash, low
margin of safety
Ethosuximide:
Ind: Absence seizures
Dose: 20-25 mg/kg/d in 2 doses
Half Life: 4-30 hrs
SE: Photophobia, WBC, nephrosis, blood
dyscrasia
ACTH:
Ind: West syndrome
Dose: 20-40 u/d for 4-6 wks
SE: hypercortisolism
Nitrazepam
Ind: Myoclonus, atypical absence
Dose: 0.5 mg/kg/d in 2 doses
SE: Sleepiness, salivation,hypotonia, ataxia, tolerance
Clonazepam
Dose: 0.05-0.25 mg/kg/d in 3 doses\

• Drug level monitoring

• EEGs
• When to stop ? 2-3 yrs seizure free
Newer AEDs
Clobazam
Ind: Partial, generalised & myoclonus (add on drug)
Dose: 0.5 mg/kg/d single dose
SE: Drowsiness, tolerance,  secretions
Gabapentin
Ind: Secondarily generalised, complex partial
SE: liver enzymes, impaired swallowing & aspiration,
somnolence, fatigue, dizziness, wt gain
Lamotrigine
Ind: Generalised, absence, JME, LG syndrome
SE: Synergy with valproate, skin rash, SJ syndrome
Newer AEDs/ Other modalities
Topiramate:
Ind: Partial, generalised, drop attacks, LG syndrome
SE: ?cognitive impairment
Vigabatrine:
Ind: Partial, infantile spasms
Dose: 40-80 mg/kg/d
SE: Drowsiness, agitation, confusion
Oxcarbazepine:
Derivative of carbamazepine
• Ketogenic diet
• Surgery