Seizure Disorders in Children

Dr. 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
Prevalence
No data available in Nepal.
Seizure disorders: 360/100,000 (India, Saha SP
2003).
Prevalence of seizure disorder in children has
been reported to be 350/100,000 (Gortmaker
and Sappenfield, 1984). However, 3-5% of all
children will have one or more seizures
(Haslem, 2000). The incidence of epilepsy (new
cases per year) has been reported to be
50/100,000, with 75% of people developing
epilepsy doing so prior to 20 years of age
(Holmes, 1992)
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 years
In over 65% of patients, epilepsy begins in
childhood.
Recurrent seizures during fever in an 24
month old

History
A 24 month old boy was seen in the KCH emergency room following a
seizure accompanied by fever, his second in 6 months. The child had
been well until the previous day, when parents notices fever for which he
was take to a doctor who prescribed amoxicillin for the diagnosis of
URTI.
The following morning, the boy experienced a 2 minute generalized
stiffness just as father was administering amoxicillin. Afterwards, he was
rushed to the KCH.The child resumed normal alertness on way to the
hospital.
Prior seizures had occurred at the ages of 18 and 20, months with fever
in each instance. Prior seizures were otherwise identical in duration and
character.
Past medical history was noncontributory. Development was normal, with
independent walking at 12 months and present use of single sentences.
Review of family history revealed that an older sister had suffered from
similar seizures during fever until age 3.
Recurrent seizures during fever in an
24 month old
Physical Exam
In the emergency room, the boy was alert and
appeared only minimally ill. Temperature was 38.4.
General physical exam revealed a dull and
erythematous left tympanic membrane and mild
cervical adenopathy. No nuchal rigidity or other
meningeal signs were apparent.
Neurologic examination was entirely nonfocal and
the child's motor skills, language, and social
interaction seemed normal for age.

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, encef)halitis. .
(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
23 days).
Classification of Epileptic Seizures
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
Source: Nelsons Textbook of Pediatrics, (17
th
ed.)
Classification of Epileptic Seizures
Generalized seizures
Absencess
Typical
Atypical
Generalized tonic clonic
Tonic
Clonic
Myoclonic
Atonic
Infantile spasms
Unclassified seizures
Source: Nelsons Textbook of Pediatrics, (17th ed.)
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: Nelsons 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.