SEIZURE DISORDERS IN CHILDRENDr. Pushpa Raj Sharma FCPS

Professor of Child Health

Institute of Medicine

Definitions

Seizure: A sudden, involuntary, time-limited alteration in behavior, motor activity, autonomic function, consciousness, or sensation, accompanied by an abnormal electrical discharge in the brain

Definitions

Epilepsy: A condition in which an individual is predisposed to recurrent seizures because of a central nervous system disorder

Status Epilepticus: More than thirty minutes of continuous seizure activity, or recurrent seizures without intercurrent recovery of consciousness

Neurology Chapter of IAP

Introduction

Convulsion associated with febrile disease 2-4% of all children before the age of 5 years

Symptomatic seizures 0.5-1%

Epilepsy: Recurrent unprovoked seizures

First year of life: 1,2/1 000

Childhood and adolescents: 0,5-1/10000

Neurology Chapter of IAP

Aetiology of Epilepsy

Specific aetiology Identifiable in only 30% of cases

Idiopathic 67.6% Congenital 20%

Trauma HIE Congenital brain anomalies

Trauma 4.7% Infection 4.0% Vascular 1.5% Neoplastic 1.5% Degenerative 0.7%

Neurology Chapter of IAP

Seizure type

Partial (Only a portionof the brain)

- Simple(Normal consciousness)- Complex(Impaired consciousness)

Generalized(Both hemispheres areinvolved)

Burden of the problem

Per 100,000 people, there will be: 86 seizures in the first year of life 62 seizures between 1 and 5 years 50 seizures between 5 and 9 years 39 seizures between 10 and 14 yearsIn over 65% of patients, epilepsy begins in

childhood.

DETAILED HISTORY OF THE CHILD WITH CONVULSION

• Mode of onset of convulsion, character, duration, any similar previous history (chronic/recurring).

• Triggering factors- fever, toxic substance or drug, metabolic dis- turbance.

•  Family history of convulsion, inborn error of metabolism.

• Peri-natal/Natal history-birth asphyxia, jaundice, birth trauma, central nervous system (CNS) infection e.g. meningitis, encephalitis etc.

• CNS status-cerebral palsy, mental retardation (learning difficulty), any post-convulsive state.

CONVULSION IN INFANTS AND OLDER CHILDREN

A) Acute/Non-recurring    (i) with fever: febrile convulsion, infections e.g. meningitis    (ii) without fever: poisoning including medicinal overdose, metabolic disturbance

e.g. hypoglycaemia, hypocalcaemia and electrolyte imbalance, head injury, brain tumour, epilepsy.

B) Chronic/Recurring :    (i) with fever: recurrent febrile convulsion, recurrent meningitis.    (ii) without fever: epilepsy.

Febrile seizures

Febrile convulsions, the most common seizure disorder during childhood

Age dependent and are rare before 9 mo and after 5 yr of age.

A strong family history of febrile convulsions.

Usually generalized, is tonic-clonic and lasts a few seconds to 10-min

Mapped the febrile seizure gene to chromosomes 19p and 8q13-21.

Atypical febrile seizures

The duration is longer than 15 min. Repeated convulsions occur within the

same day. Focal seizure activity or focal findings

are present during the postictal period.

Treatment of febrile seizures

A careful search for the cause of the fever. Use of antipyretics. Reassurance of the parents. Prolonged anticonvulsant prophylaxis for

preventing recurrent febrile convulsions is controversial and no longer recommended.

Oral diazepam, 0.3 mg/kg q8h (1mg/kg/24hr), is administered for the duration of the illness (usually 2–3 days).

Classification of Epileptic Seizures

Partial seizures: Simple partial (consciousness retained)

MotorSensoryAutonomicPsychic

Complex partial (consciousness impaired)Simple partial, followed by impaired consciousnessConsciousness impaired at onset

Partial seizures with secondary generalizationSource: Nelson”s Textbook of Pediatrics, (17th ed.)

Simple partial - motor

Classification of Epileptic Seizures Generalized seizures

Absences Typical Atypical

Generalized tonic clonic Tonic Clonic Myoclonic Atonic Infantile spasms

Unclassified seizures

Source: Nelson”s Textbook of Pediatrics, (17th ed.)

Absence – Petit Mal

• sudden cessation of motor activity or speech with a blank facial expression and flickering of the eyelids

• more prevalent in girls• rarely persist longer than 30 sec• do not lose body tone

Generalized Tonic-clonic – Grand Mal

• suddenly lose consciousness and in some cases emit a shrill, piercing cry

• eyes roll back, their entire body musculature undergoes tonic contractions, and they rapidly become cyanotic in association with apnea

• clonic phase of the seizure is heralded by rhythmic clonic contractions alternating with relaxation of all muscle group

Mimicking seizures Benign paroxysmal vertigo Night terrors Breath-holding spells Syncope Paroxysmal kinesigenic Choreoathetosis Shuddering attacks Benign paroxysmal torticollis of infancy Hereditary chin trembling Narcolepsy Rage attacks Pseudo seizures Masturbation

Status Epilepticus

Three major subtypes: prolonged febrile seizures idiopathic status epilepticus symptomatic status epilepticus

Higher mortality rate. Severe anoxic encephalopathy in first few

days of life. History. The relationship between the neurologic

outcome and the duration of status epilepticus is unknown in children.

Treatment of status epilepticus Initial treatment:

assessment of the respiratory and cardiovascular systems;

A nasogastric tube insertion; IV catheter; a rapid infusion of 5 mL/kg of 10%

dextrose; blood is obtained for a CBC and for

determination of electrolytes. a physical and neurologic examination.

Source: Nelson”s Textbook of Pediatrics, (17th ed.)

Treatment of status epilepticus Drugs:

should always be administered IV; phenytoin forms a precipitate in glucose solutions; have resuscitation equipment at the bedside; A benzodiazepine (diazepam) may be used initially; if the seizures persist, phenytoin is given

immediately The choices for further drug management include

paraldehyde, a diazepam infusion, barbiturate coma, or general anesthesia.