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Understanding Nonfebrile Seizures in Children: Evaluation and Treatment

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Learn about nonfebrile seizures in children - history, symptoms, evaluation, and treatment options. Get insights on associated factors and precautions to take.

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Understanding Nonfebrile Seizures in Children: Evaluation and Treatment

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  1. Good Morning! Welcome Applicants! October 21, 2011

  2. First Nonfebrile Seizure What to do?

  3. Nonfebrile seizure • 25,000 to 40,000 per year • Cannot be explained by an immediate, obvious provoking cause such as head trauma or intracranial infection

  4. History

  5. Associated factors • Age • Family History • Developmental Status • Behavior • Health at seizure onset – febrile, ill, exposed to illness, sleep deprived • Precipitating event other than illness – trauma, toxins

  6. Symptoms during seizure • Aura • Behavior • Preictal symptoms • Vocal • Motor • Head or eye turning, eye deviation, posturing, jerking, stiffening, automatisms • Respiration • Autonomic • Pupillary dilation, drooling, incontinence, vomiting • Loss of consciousness

  7. Symptoms following seizure • Amnesia • Confusion • Lethargy • Sleepiness • Headaches • Muscle aches • Transient focal weakness (Todd’s paresis) • Nausea or vomiting

  8. Is it really a seizure? • Breath-holding spells • Syncope • GERD • pseudoseizures

  9. Physical

  10. Physical Exam • State of consciousness, language, social interaction • Global development • Dysmorphic features, neurocutaneous skin findings, organomegaly, limb asymmetry • Head circumference • Neuro exam • Cranial nerves • Motor strength and tone • Reflexes • Gait • Cerebellar and sensation tests

  11. Evaluation

  12. Laboratory studies

  13. CBC, BMP, Calcium, Tox screen? • Recommendations • Should be ordered based on individual clinical circumstances that include suggestive historic or clinical findings such as vomiting, diarrhea, dehydration, or failure to return to baseline status • Toxicology screening should be considered across the entire pediatric age range if there is any question of drug exposure or substance abuse

  14. Exception to the rule • Children under 6 months of age • Some studies show a 70% incidence of hyponatremia associated with seizures in this age group

  15. Lumbar puncture

  16. Lumbar puncture • Recommendation • In the child with a first nonfebrile seizure, LP is of limited value and should be used primarily when there is concern about possible meningitis or encephalitis

  17. EEG

  18. EEG • Recommendation • The EEG is recommended as part of the neurodiagnostic workup of the child with an apparent first unprovoked seizure

  19. EEG • Helps to determine seizure type, epilepsy syndrome, and risk for recurrence • Optimal timing is not clear • An EEG done in the first 24 hours will most likely show abnormalities, but can be due to postictal slowing • There is no evidence that the EEG must be done before discharge from the ED • Can be arranged on an outpatient basis

  20. Neuroimaging

  21. Neuroimaging • Recommendations • If a study is obtained, MRI is the preferred modality • Emergent neuroimaging should be performed in a child of any age who exhibits a postictal focal deficit or who has not returned to baseline within several hours after the seizure • Nonurgent neuroimaging with MRI should be seriously considered in any child with a significant cognitive or motor impairment of unknown etiology, unexplained abnormalities on neuro exam, a focal seizure, an EEG that does not represent a benign partial epilepsy of childhood or primary generalized epilepsy, or in children under 1 year of age

  22. Treatment

  23. To Treat or not to Treat? • Discuss all strategies with patient/parents • Antiepileptic drugs • Special diets (ketogenic diet) • Surgery • Vagus nerve stimulation • Most neurologists do not recommend AEDs after a first seizure because only 30% have a second seizure • After 2 seizures, the risk of having a third one increases to about 75% without treatment • AED is usually started after 2 seizures • 1/3 of patients are refractory to medication

  24. Seizure Precautions

  25. Precautions • Patient/parents should be informed about possible precipitating factors: • Sleep deprivation • Hyperventilation • Alcohol abuse • Recreational drugs • Photic light stimulation

  26. Can they play sports? • Yes! They can participate in sports • Basic safety precautions • No swimming or bathing alone

  27. Can they drive? • Yes! They can drive • Each state has different laws • Most suggest being seizure free for 6-months

  28. Outer Ear Disease, Dr. Simon Noon Conference

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