SEIZURES IN

CHILDREN

Presenter: Dr. Kiprono

 Outline
Definition/ Introduction
Aetiology
Classification
Clinical features
Investigations
Treatment
Differential diagnosis
Febrile seizures
Neonatal seizures
Status Epilepticus
 Definitions

Epilepsy
Epilepsy is a chronic brain disorder characterized by repetitive
unprovoked seizures more than two times 24 hours apart in a year.

Seizure
A seizure is a transient physical manifestation of a sudden excessive and
uncontrolled electrical activity of the brain that is usually self-limiting.

Other commonly used terms for seizure:

Convulsions Motor seizure
Fits Colloquial term for seizure
Attack Colloquial term for seizure
Kifafa Kiswahili word for epilepsy
There are four components of a seizure that can be distinguished but not
all seizure types will have all four components:

i) Prodromal phase- few minutes to hours or even days before the

actual seizure. May include headache, irritability, insomnia, bad temper
ii) Aura
 An aura precedes the clinically apparent seizure by seconds or a few
minutes. Often vague and indescribable e.g unpleasant smell
iii) Seizure (ictus)
Important characteristics to note include the:
 Type of seizure
 Duration of seizure
 Frequency of seizure
 Time of occurrence of the seizure and its relation to sleep
iv) Post-ictal phase
 This phase may be absent, brief or may last several hours, and
sometimes even days. Among children, there may be dullness, lethargy
and lack of appetite.
 Aetiology of Seizures:

1. Metabolic disorders
 Hyperglycaemia
 Hyponatraemia
 Hypoglycaemia
 Hypernatraemia
 Hypomagnesaemia
 Hypocalcemia.
2. Infections
 Meningitis
 Encephalitis
 Abscess
 Septicaemia
 Parasitic infestations like Malaria.
 Aetiology of Seizures

3. Tumours / intracranial SOL

 Malignancies: Primary/ secondary
 Cystic lesions e.g. Hydatid cyst, cysticercosis
 Others e.g. Foreign Bodies, inflammatory lesions, effusions
4. Inherited conditions
 Storage diseases
 Metabolic diseases e.g. porphyrias
 Deficiency e.g. pyridoxine dependency
 Neurocutaneous disorders e.g. Tuberous sclerosis, neurofibromatosis etc.
5. Systemic disorders
 Vasculitis
 Encephalopathy of hypertension
 Renal failure
 Hepatic failure
 Aetiology of Seizures

6. Drugs
 Lead
 Addictive drug withdrawal
 Alcohol withdrawal.
7. Toxins
 organophosphates,
 carbamates.
8. Trauma to the head
 concussion,
 contusion.
9. Disorders of neurodevelopment
 Neuronal/ neuroblast migration disorders
 Dysplasias
 Dysgenesis
10. Idiopathic.
Seizure Precipitating Factors
 SEIZURE CLASSIFICATION

1. Partial seizure (focal or localised)

(A) Simple Partial seizures
 With motor signs.
 With somatosensory or special sensory systems.
 With autonomic symptoms or signs.
 With psychic symptoms.
(B) Complex partial seizures
 Simple partial at onset followed by impairment of consciousness
 With impairment of consciousness at onset
(C) Partial seizure evolving to secondarily generalised
seizures
 Simple partial seizures evolving to generalised seizure
 Complex partial seizures evolving to generalised seizures
 Simple partial seizures evolving to complex partial then to generalised
seizures.
11. Generalised
 Absence seizures
 Tonic clonic (grand mal epilepsy)
 Tonic

 Clonic
 Akinetic/ atonic
 Myoclonic
 Seizures

YES
Loss of
Consciousness

YES NO
Generalized Partial
Seizures Seizures

YES
Alteration of
Consciousness

YES NO
Complex
Simple Partial
Partial
 Clinical features

Depend on:
 the type of seizure manifested,
 the aetiology

1. Partial Seizures
A. Simple partial seizures
 Consciousness retained through the episode.
 Manifestation may be motor, sensory or autonomic.
 Depends on the part of the brain primarily affected.
 Precentral gyrus focus presents motor activity.
 Sensory features - Postcentral gyrus activity.
 Autonomic presentation e.g. nausea, palpitations in temporal and
frontal lobes focus.
 Clinical features

1. Partial Seizures
B. Complex partial seizures
 Associated impairment of consciousness.
 Impaired consciousness either at onset or secondary.
 Aura present (often not recognised).

C. Partial seizure secondarily generalised.

 Initial simple partial seizure spreads to other parts.
 Complex partial seizures evolving to generalised seizures.
 Simple partial evolves to complex partial then generalised.
 Clinical features

2. Generalised seizures
A. Absence seizure
 Mainly affect children in the school going age between 5
-15 years.
 Brief episodes of sudden interruption of ongoing activity,
blank stare, altered tone
 Associated loss of consciousness over this period

 Minimal or no motor manifestation

 No memory of the event
 Easily provoked by hyperventilation
 Clinical features

2. Generalised seizures
B. Tonic clonic seizure
 Is associated with convulsion involving various muscle groups
 Generalised seizures have bilaterally synchronous onset and
generalised EEG features commonly.
 Tongue biting and/or incontinence of urine/stool may occur.
C. Tonic
- Sudden sustained muscle contraction.
 Clinical features

2. Generalised seizures
D. Clonic.
 Repeated muscle jerk like activity
E. Akinetic/ atonic.
- Sudden loss of muscle tone.
- Presents like faint attack/syncope
F. Myoclonic
-Isolated muscle group jerk like epsodes.
 Diagnosis
 The diagnosis of epilepsy has important and far-reaching
physical, psychosocial and economic implications to the
patient. It is therefore important that the diagnosis is
correct.
 Detailed Seizure History
 Current episode: Ictal, pre-ictal, post ictal
 Onset, time, frequency, triggers
 Perinatal History
 How was the delivery?
 Developmental history
 Family and Social History
 Physical and General examination
 Investigations

Are many and will be influenced by the differential diagnosis:

 Random blood sugar
 Full Haemogram
 Blood slide for Malaria parasites
 Blood biochemistry
 Liver function tests
 Cerebrospinal fluid assay
 Chemical analysis for poisoning
 Skull x-ray
 EEG
 CT scan / MRI scan.
Electroencephalography
Electroencephalography (EEG) is often helpful in the
diagnosis and classification of epilepsy
A person with established epilepsy may have normal
EEG findings, and therefore normal findings on EEG
do not exclude a diagnosis of epilepsy.
 Management of Epilepsy

Initiation of treatment
 Start treatment with one drug.
 Start treatment using the lowest recommended dose compatible with
the medication preparation.
 Gradually adjust dosage at two to six weeks intervals until complete
seizure control or the maximum pharmacologically tolerated dose is
reached. This is the patient’s minimum maintenance dose.
 If no seizure control is achieved after attaining the maximum dosage of
the initial drug, a second drug should be added while considering
gradually reducing or maintaining the initial drug depending on the
clinical response.
When to withdraw drugs
 Drug withdrawal should be considered if the patient has
been seizure-free for two to three years.
 This should be done in a very gradual manner over three to
six months. In case of poly-therapy, each drug should be
withdrawn separately one after the other.
 Antiepileptic Drugs

Phenobarbitone
 The main indications are the idiopathic generalized epilepsies. It
is also effective in other generalized seizures and in partial seizures.

 Phenobarbitone has a long half-life time (≥ 2 days ) and therefore takes

a few weeks before reaching a plasma steady state. This also means that
it can be given once a day, preferably after the evening meal before
retiring to bed and dose adjustment carried out after three to four
weeks.
 Main side-effects of phenobarbitone are drowsiness and changes in
behaviour, such as hyperactivity and/or aggressiveness in some
children.

 Loading with 15mg/kg (if NOT on maintenance phenobarb)

followed by 2.5mg - 5mg/kg daily
Phenytoin
 Effective for partial seizures (with or without generalization), primary
GTCS and seizures during sleep in some patients.
 Has a long half-life, which is furthermore dose-dependent, being longer
at higher doses, and it may take up to two weeks before it becomes
effective.
 It can be given as a once daily dose. It is slightly irritating to the
stomach and therefore, should always be given after a meal and when
the dosage is high, it might be better to divide it into two doses.
 Phenytoin side-effects are many and include drowsiness, gum
hypertrophy, hirsutism, ataxia and nystagmus.
 Age 1 mo-12 years (IV, oral) Loading dose: 15-20 mg/kg; maintenance
dose of 2.5 - 5 mg/kg twice daily (max. 150mg twice daily) Similar
dosing can be used in neonates.
Diazepam
 Mainly used as first line treatment for status epilepticus, or
prolonged febrile convulsions
 Never as intra muscular injections (IM).
 Intramuscular Diazepam takes minutes to hours to be
mobilized. Multiple IM doses may lead to respiratory
depression with potentially fatal outcomes.
Half-life, 10-20 hours, longer in newborns.
 Danger of accumulation
 Dosage: 0.3mg/kg IV or 0.5mg/kg PR
Carbamazepine
 Main indications are partial seizures and some generalized tonic clonic
seizures.
 It does not have a long half-life and therefore cannot be given once
daily. It should be given twice daily and when combined with other
drugs it should be given three times daily.
 Side effects include drowsiness, slurred speech and dizziness at
initiation of treatment or when the dosage becomes too high. Double
vision and ataxia also occur at high doses.
 Age 1 m - 12yrs: initially 5 mg/kg at night, increased as necessary
by 2.5 - 5 mg/kg every 3 -7 days; usual maintenance dose 5 mg/kg
2-3 times daily.
Sodium Valproate
 Main indications are generalized seizures; absence
seizures, myoclonic seizures, and atonic seizures. Also used
for the Generalised Tonic Clonic Seizures occurring after
awakening.
 Has a short half-life and should be given three times daily
in order to avoid high peak concentrations.
 Specific side-effects include increase in body weight, loss of
hair, and gastric irritation.
 Neonate initially 20mg/kg once daily; maintenance 10 mg/kg twice
daily PO 1 mo – 12 yrs initially 10-15 mg/kg (max. 600mg) daily in
1-2 divided doses max 60 mg/kg daily. Maintenance 25-30 mg/kg
daily in 2 divided doses PO
 FEBRILE SEIZURES

Age of occurrence is 6 month to 6 years.

Always associated with fever.
Diagnosis of exclusion.
Occurs in boys more commonly than girls.
Usually generalised tonic clonic but can take any
form.
Chances of recurrence are higher in those whose
onset was at infancy.
 Febrile Seizures

 Epilepsy may develop in later life.

 Status epilepticus can occur.
 Complicated febrile seizures (atypical):
 are prolonged (>15 minutes),
 focal or
 several episodes within the same illness
 Exclude CNS infections like meningitis.
 An important factor in managing febrile convulsions lies in fever
control.
 Acute treatment is indicated for prolonged seizures. Where a seizure
continues for more than five minutes, diazepam should be
administered, either 0.3mg/Kg slowly intravenously or rectally at
0.5mg/Kg
 Febrile Seizures

Investigations are variable.

EEG not routine test; usually it is normal.
Treat the cause; control fever; and the convulsion.
Long term prophylaxis with Phenobarbital useful.
Prophylaxis is not mandatory (the American
Academy of Paediatrics - 2001)
 NEONATAL SEIZURES

GTC seizures tend not to occur during the first month

of life – incomplete arborization of axons and
dendritic processes, incomplete myelination.
At least 5 seizure types seen in neonates
 Focal seizures
 Tonic
 Clonic – focal/multifocal
 Myoclonic
 Subtle seizures eg chewing motions,
nystagmus, apnoea, peddling movts, etc
 NEONATAL SEIZURES

CAUSES
 Hypoxic Ischaemic encephalopathy (Birth
asphyxia)
 Hypoglycaemia SGA, IDM
 Hypocalcaemia LBWs, IDM
 Hyponatremia / Hypernatremia
 Hypomagnesaemia
 NEONATAL SEIZURES

 Intracranial hemorrhage – upto 15% of cases

 Infection
 Inborn error of metabolism
 Idiopathic (no cause found 10% of cases)
 Drug withdrawal
 Developmental defects
 Deficiencies eg pyridoxine
 Benign familial neonatal seizures
 Trauma
 NEONATAL SEIZURES

Certain syndromes have seizures as part of the

syndrome description eg Aicardi, incontinentia
pigmenti, tuberous sclerosis
Unintentional injection of a local anaesthetic into a
fetus during labour
 Investigations

Blood Glucose
Calcium :Low Ca seen in birth trauma, CNS insult in
the perinatal period, Maternal DM, Prematurity, Di
George syndrome, high PO4 feedings
Magnesium
UECs
LP
Cranial US
CT Scan #Metabolic work up #EEG
 Neonatal seizures management

ABCs to ensure adequate ventilation and perfusion

Hypoglycaemia (Dextrose 10 %)
Hypocalcaemia (Calcium gluconate 10 %)
Hypomagnesaemia ( Mg So4)
Antibiotics ( If there is infection)
Correct electrolyte abnormalities
Anticonvulsants ( PB, Phenytoin, Na Valproate)
Trial of pyridoxine for refractory seizures
 Status Epilepticus

Convulsive Status epilepticus is a common medical

emergency.
It is characterized by continuous, convulsive seizures
lasting more than 5 minutes or two or more seizures
during which the patient does not return to baseline
consciousness
 Management of status epilepticus

Airway, Breathing and Circulation should be

managed as per standard emergency guidelines
(APLS, ATLS etc.).
On gaining intravenous access, blood samples should
be taken to assess blood glucose. Other initial
investigations that can be considered at this stage
depending on clinical presentation and availability of
resources include electrolytes assessment, malaria
test, full haemogram and liver function tests.
 If hypoglycaemia is confirmed or suspected, administer
5mls/kg of 10% dextrose.
 Administer 0.3mg/kg of diazepam intravenously over an
approximate rate of 1mg/min, until seizures stop or up to 5
mg in children under 2 years: 5-10 mg in children 2-12
years; and 10mg in older individuals. This may be repeated
after 10 minutes if the seizures persist.
N.B. Do not give diazepam intramuscularly.
 If the seizures persist 20 minutes after administration of
the second dose of diazepam, consider using phenobarbital
or phenytoin as follows:
Phenytoin
 Administer a loading dose of phenytoin intravenously at 15-
18 mg/kg over a period of 30 minutes, not exceeding 1,000
mg, or give 5-6 mg/kg IV three times with 30 min in
between.
Phenobarbitone
 15 mg/kg as a loading dose IM or slow IV infusion (when
given IV, closely monitor the pulse, respiration and blood
pressure)
 Do not use phenobarbitone or phenytoin for patients with
epilepsy who are currently using either drug as part of their
epilepsy treatment.
 After the loading dose is given, continue with the
maintenance dose of the drug used. Thus, phenytoin will be
administered at 2.5mg/kg twice a day and phenobarbital at
3-5 mg/kg once a day. If the patient is able to tolerate oral
medication, provide the maintenance orally.
 If the seizures are refractory to second line treatment,
consider use of continuous infusion of a benzodiazepine
such as midazolam or use of anaesthetic agents like
thiopental.
 Such considerations should be made in consultation with a
senior health worker, or in a facility with capability for close
monitoring and mechanical ventilation if necessary.
QUESTIONS?