Dr. Dafalla Ahmed Babiker
Jazan University
change in motor activity and/or behaviour due to abnormal electrical activity in the brain.
seizures in children either
- provoked by somatic disorders originating outside the brain, such as high fever, infection, syncope, head trauma, hypoxia, toxins, or cardiac arrhythmias
or - triggered recurrently from within the brain ,this is called epilepsy(Less than one third of seizures in children are caused by epilepsy)
epilepsy is considered to be present when two or more unprovoked seizures occur at an interval greater than 24hr apart within 6 month.
lifetime incidence of epilepsy is 3% and
more than half of cases begin in childhood.
prognosis is generally good, but 10–20% have persistent seizures refractory to drugs
Motor seizures may be focal or generalized and
- tonic-clonic - tonic (increased tone or rigidity) - clonic (rhythmic muscle contraction and
relaxation) - myoclonic (shock like contraction of a
muscle) - atonic (flaccidity or lack of movement
during a convulsion)
The most common seizure disorder during childhood, generally have an excellent prognosis
Be careful the underlying cause may be serious disease such as sepsis or bacterial meningitis.
So the child must be carefully examined and appropriately investigated for the cause of the fever , especially when it is the first seizure
There is genetic predisposition
Simple febrile seizures
usually associated with a core temperature that increases rapidly to 39°C or more
From 3 mo to 5 yr
Lasts less than 15 min
Once in 24 hr
Usually in the 1st 24 hr of the febrile illness
Generalised tonic clonic Family history of febrile seizures (not necessary)
Complex febrile seizures
Duration more than 15 min , recur more than once in 24 h, focal .
children with simple febrile seizures are at no greater risk of later epilepsy
If any doubt exists about the possibility of meningitis, a lumbar puncture with examination of the cerebrospinal fluid (CSF) is indicated.
If the child is less than 12 mo and the febrile seizure is complex strongly consider LP
EEG may be useful for evaluating patients with an atypical feature or with other risk factors for later epilepsy
ABC .
Benzodiazepine to control seizure
careful search for the cause of the fever
control the fever, by using antipyretics
To reduce the risk of febrile seizure :-
At the onset of each febrile illness, give oral diazepam,three times per day for 2–3 days? plus oral antipyretic .
First Seizure history before seizure during seizure detailed
description after seizure look for life-threatening causes of seizures
such as meningitis, systemic sepsis, head trauma, and ingestion of drugs
family history of epilepsy , neurologic
disorder, or history of seizure with fever
Physical examination
Temperature, blood pressure
CNS
Fundus examination
CVS
Hepatosplenomegaly (metabolic or storage disease)
Neurocutanous manifestations
serum electrolytes, toxicology screening, or urine and serum metabolic testing should be chosen based on individual clinical circumstances rather than on a routine basis
Blood glucose level and calcium should be tested especially in infants.
EEG , is recommended for identification of specific focal abnormalities and/or epileptic syndromes
Lumbar puncture is not recommended. Unless meningitis is suspected .
Neuroimaging is generally not recommended unless there is an indication for it on neurologic examination. MRI is superior to CT scan
Anticonvulsant medication is generally not recommended
Recurrent Seizures
Two unprovoked seizures greater than 24 hours apart within 6 mo, suggest the presence of an epileptic disorder
Seizures that occur during the early morning hours or with drowsiness, particularly during the initial phase of sleep, are common in childhood epilepsy.
irritability, mood swings, headache, and subtle personality changes may precede a seizure.
Ask parents to act out or re-create the
seizure, it is much more accurate than the verbal description
Ask about the frequency, time of day,
precipitating factors
A prolonged personality change or intellectual deterioration may suggest a degenerative disease of the CNS
constitutional symptoms, including vomiting and failure to thrive in infants, might indicate a primary metabolic disorder
History of anticonvulsant medication Family history of epilepsy Impact on schooling, activities,
psychosocially
full physical examination especially ophthalmologic and neurologic examination, can provide information about the presence of increased intracranial pressure. neurocutaneous or neuromatabolic syndromes. and structural brain abnormalities including malformations, injuries, infections, or tumors.
The EEG is indicated in all cases of epilepsy and is useful for determining the type of epilepsy and the future prognosis
MRI is indicated in children with newly diagnosed epilepsy , especially for those with neurologic deficits, partial seizures, or focal EEG
. PARTIAL SEIZURES Simple partial (consciousness
retained) Motor Sensory Autonomic Psychic Complex partial
(consciousness impaired) Simple partial, followed by
impaired consciousness Consciousness impaired at
onset Partial seizures with
secondary generalization
GENERALIZED SEIZURES Absences Typical Atypical Generalized tonic-clonic Tonic Clonic Myoclonic Atonic Infantile spasms UNCLASSIFIED SEIZURES
Large proportion of childhood seizures, up to 40%
classified as simple or complex Aura is more frequent in partial than in
generalized Simple Partial Seizures should be
differentiated from ticks Lip smacking, chewing, swallowing, and
excessive salivation are common features of complex Partial Seizures
Spreading of the epileptiform discharge during CPS can result in secondary generalization with a tonic-clonic convulsion
common type of partial epilepsy in childhood and has an excellent prognosis
peak age of onset of 9–10 yr motor signs and sensory symptoms are
often confined to the face Unilateral tonic-clonic contractures of the
lower face and clonic movements or paresthesias of the ipsilateral extremities. Consciousness may be intact or impaired, and the partial seizure may proceed to secondary generalization.
BPEC occurs during sleep in 75% of patients
The EEG pattern is diagnostic for BPEC and is characterized by a repetitive spike focus localized in the centrotemporal or rolandic area
Carbamazepine is the preferred drug, which is continued for at least 2 yr or until 14–16 yr of age, when spontaneous remission of BPEC usually occurs.
Absence Seizures.
Simple (typical) absence (petit mal) seizures are characterized by a sudden cessation of motor activity or speech with a blank facial expression and flickering of the eyelids
These seizures, which are uncommon before age 5 yr, are more prevalent in girls
No aura, no postictal state
Lasts for less than 30sec
Hyperventilation for 3–4 min routinely produces an absence seizure.
The EEG shows a typical 3/sec spike and generalized wave discharge
Generalized Tonic-Clonic Seizures very common may follow a partial seizure with a focal
onset (secondary generalization) or from the start.
They may be associated with an aura, suggesting a focal origin of the epileptiform discharge
Patients suddenly lose consciousness , may bite their tongue . Loss of sphincter control, particularly the bladder.
Postictally, children initially are semicomatose and typically remain in a deep sleep from 30min to 2h
Idiopathic seizure is a term applied when the cause of a generalized seizure is unknown
Myoclonic Epilepsies of Childhood
This disorder is characterized by repetitive seizures consisting of brief, often symmetric muscular contractions with loss of body tone and falling . 5 subgroupes
- Benign myoclonus of infancy
- Typical myoclonic epilepsy of early childhood.
- Complex myoclonic epilepsies
- Juvenile myoclonic epilepsy (janz syndrome).
- Progressive myoclonic epilepsies
Infantile Spasm (west syndrome)
Usually begin between the ages of 4 and 8 mo
characterized by brief symmetric contractions of the neck, trunk, and extremities
three types of infantile spasms: flexor, extensor, and mixed which is the most common type
Clusters of seizures may persist for minutes
EEG that is associated with infantile spasms is referred to as hypsarrhythmia
Infantile spasms are typically classified into two groups: cryptogenic and symptomatic
Infants with cryptogenic infantile spasms have a good prognosis, whereas those with the symptomatic type have an 80–90% risk of mental retardation
Ensure that the patient has a seizure disorder and not a condition that mimics epilepsy
If 1st attack with negative family history, negative result on a neurologic examination and EEG usually supports the approach of watchful waiting rather than administration of an anticonvulsant . Approximately 70% of these children will not experience another convulsion.
Family education
The drug of choice depends on the classification of the seizure
use of only one drug for the control of seizures. The drug is increased slowly until seizure controled ,if not controled add an other drug as adjunctive therapy
If complete seizure control is achieved by an anticonvulsant, a minimum of 2 seizure-free years for a patient with no risk factors is adequate and safe period of treatment. then tapper gradually over 3 -6 mo
risk factors includ
- age greater than 12 yr at onset
- neurologic dysfunction (motor handicap or mental retardation), a history of prior neonatal seizures,
- numerous seizures before control is achieved
Carbamazepine Generalized tonic-clonic , Partial
Clonazepam infantil spasm ,Absence, Myoclonic
Ethosuximide May increase tonic-clonic seizures , used for Absence
Gabapentin Adjuntive therapy
Lamotrigine Adjunctive therapy
Nitrazepam Absence , Myoclonic , Infantile spasms
Phenobarbital Generalized tonic-clonic , Partial, Status epilepticus
Phenytoin Generalized tonic-clonic ,Partial, Status epilepticus
Valproic acid Generalized tonic-clonic,Absence Myoclonic,Partia
Vigabatrin ,Infantile spasms,Adjunctive therapy
Status epilepticus is defined as a continuous convulsion lasting longer than 30 min or the occurrence of many convulsions between which there is no return of consciousness
Treatment :- in the ICU
- ABC
-pulse, temperature, respirations, and blood pressure are recorded
- gentle suction
- oxygen face mask ,ambu bag , assisted ventilation
-If hypoglycemia is confirmed by Dextrostix, a rapid infusion of 5mL/kg of 10% dextrose
Drugs should always be administered IV in the management of status epilepticus
benzodiazepine (diazepam, lorazepam, or midazolam)
loading dose of phenytoin infusion (ECG) In some centers, loading dose of
phenobarbital is given before phenytoin paraldehyde, a diazepam infusion,
barbiturate coma (thiopental)or general anesthesia (halothane , isoflurane)
when you insert the IV line blood is obtained for a CBC and electrolytes (including calcium, phosphorus, and magnesium), glucose, creatinine, lactate, and anticonvulsant levels, if indicated
Blood and urine may be obtained for metabolic studies and toxicology
Examination of the CSF is if meningitis or encephalitis is considered , unless there is a contraindication
evidence of : trauma; papilledema, a bulging anterior fontanel, neurologic signs suggesting increased ICP; manifestations of sepsis or meningitis
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