Seizures in Childhood

1. Seizures in Childhood Neurology Chapter of IAP

2. Reference • Paediatrics & Child health Coovadia and Wittenberg p.477-483 • Lecture on AED Neurology Chapter of IAP

3. 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

4. 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% Aetiology of Epilepsy Neurology Chapter of IAP

5. Seizure type - Simple (Normal consciousness) - Complex (Impaired consciousness) Partial (Only a portion of the brain) Generalized (Both hemispheres are involved) Neurology Chapter of IAP

6. Epilepsy classification • Clinical presentation is quite variable • age of onset • seizure type • interictal condition • EEG • Outcome • Evaluate the: • the epileptic syndrome • Possible aetiology • The seizure type and syndrome type determine the • Specific appropriate treatment • Further evaluation Neurology Chapter of IAP

7. Neurology Chapter of IAP

8. Neurology Chapter of IAP

9. Main Periods according to Age • Neonates • Subtle, erratic, non-febrile • Infancy and early childhood • 3 months to 3 years • Febrile seizures • Infantile spasms • Lennox Gastaut • Myoclonic seizures • Status epilepticus • Partial complex Neurology Chapter of IAP

10. Main Periods according to Age • Childhood to early adolescence • Cryptogenic • Absences • Benign rolandic epilepsy • Nine years to adulthood • Primary generalized epilepsy • Focal epilepsy with brain injury Neurology Chapter of IAP

11. Neonatal seizures • Subtle seizures • Deviation of the eyes • Eyelids are flickering • Swimming or pedaling movements • Apnoeic spells • Tonic • Clonic • Myoclonic • Seldom tonic clonic seizures Neurology Chapter of IAP

12. Perinatal: HIE ICH Metabolic Hypoglycemia, hypocalcemia hypomagnesemia Other Infections Structural abnormalities Drug withdrawal Aetiology of neonatal seizures Neurology Chapter of IAP

13. Treatment of neonatal seizures • Optimize ventilation, cardiac output, BP, glucose, electrolytes and pH. • Treat the underlying disease • Intravenous line is essential • Treat the seizures promptly and vigorously • Phenobarbitone • Phenytoin Neurology Chapter of IAP

14. Non-epileptic paroxysmal events in childhood • Syncope • Breath-holding spells • Pallid: Vagal asystole • Cyanotic: Cerebra ischaemia due to a sudden rise in the intra-thoracic pressure impeding the venous return to the heart • Night terrors • Nightmares • Masturbation • Cardiac disorders Neurology Chapter of IAP

15. Non-epileptic paroxysmal events in childhood • Complicated migraine • Movement disorders • Jitteriness • Absence of abnormal gaze movements • Provoked by passive flexion or extension • Seizure jerks tend to be 2-3 Hz, clonus or jitteriness tend to be 5-6 Hz • Normal EEG • No increase in blood pressure or heart rate Neurology Chapter of IAP

16. Febrile seizures • Definition: • Seizure in children between the age of 6 months and 3-4(5) years in association with fever but without evidence of an intracranial infection • Majority occurs before the age of 3 years • Average age of onset: 18 months to 22 months • Boys more than girls Neurology Chapter of IAP

17. Febrile seizures • Recurrence • 1/3 may have at least one recurrence • The younger the age of onset the greater the risk of recurrence • Risk of developing epilepsy • 2% • Risk increases with: • Complex • Abnormal neurological state • Mesial temporal sclerosis Neurology Chapter of IAP

18. Management of febrile seizures • Identify the underlying disease • LP? • CT or MRI is not warranted in the evaluation of febrile convulsions • Routine EEG is seldom necessary • Treatment: • Long-term use of AED is not indicated • Phenobarbitone • Sodium valproate • Rectal diazepam • Antipyretics Neurology Chapter of IAP

19. Treatment of Epilepsy • Drug treatment should be regular • Simple as possible • Minimum of side effects • Monotherapy • Changes should be made gradually • High initial dosages increases side effects • Rapid withdrawal carries the risk of provoking status • Always calculate the dosage according to the weight Neurology Chapter of IAP

20. Treatment of Epilepsy • Drugs commonly used • Carbamazepine • Sodium valproate • ? Clonazepam • ? Phenobarbitone • ? Phenytoin • Newer drugs • Clobazam • Oxcarbazepine • Gabapentin • Vigabatrin • Lamotrigine NB. You are referred to the lecture on AED and the side effects should be studied! Neurology Chapter of IAP

21. Treatment of Epilepsy • AED can cause convulsions • Benzodiazepines can induce TC seizures in LGS • Carbamazepine may exacerbate absence seizures • What is used as first line treatment. • Absence: • Sodium valproate • Focal and Generalized TC: • Carbamazepine Neurology Chapter of IAP

22. Neurology Chapter of IAP

23. Status Epilpeticus • Medical emergency • Management • Abort the seizures • See figure 1 • Resuscitate the brain • ABC of resuscitation • Cerebral oedema • Mannitol • Metabolic and biochemical abnormalities • Hyperpyrexia Neurology Chapter of IAP

24. Neurology Chapter of IAP

25. Status epilepticus • Treat the cause of the seizures • ? LP • CT/MRI • Drug levels • Toxic screen Neurology Chapter of IAP

26. Status epilepticus • Correct the metabolic and systemic effects • Drop in blood pressure • Impaired brain perfusion •  Liver enzymes • Clotting defects • Hyperkalaemia • Hypoglycaemia • Inappropriate ADH • Renal failure Neurology Chapter of IAP