Seizures in Childhood

Neurology Chapter of IAP

 Reference
• Paediatrics & Child health
Coovadia and Wittenberg
p.477-483
• Lecture on AED

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 andNeurology
adolescents:
Chapter of IAP
– 0,5-1/10000
 Aetiology of Epilepsy
• Specific aetiology • Trauma 4.7%
– Identifiable in only • Infection 4.0%
30% of cases
• Vascular 1.5%
• Idiopathic 67.6%
• Neoplastic 1.5%
• Congenital 20%
• Degenerative 0.7%
– Trauma
– HIE
– Congenital brain
anomalies
Neurology Chapter of IAP
 Seizure type
- Simple
Partial (Normal consciousness)
(Only a portion - Complex
of the brain) (Impaired consciousness)

Generalized
(Both hemispheres are
involved)
Neurology Chapter of IAP
 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
 International League against Epilepsy:
Classification of epileptic seizures, using both clinical data and
electroencephalography
I. Partial seizures

A. Simple partial seizures (consciousness preserved)

 With motor symptoms

 focal motor seizures
 somato-sensory symptoms
 special sensory symptoms
 With autonomic symptoms or signs
 Flushing
 Pallor
 epigastric sensations
 sweating
 With psychic symptoms
 deja vu.
 illusions and structured hallucinations

B. Complex partial seizures (consciousness impaired)

 Simple partial onset followed by impaired consciousness

 With impaired consciousness at onset

C. Simple or complex partial seizures evolving into secondary generalized seizures

II. Generalized seizures

A. Absence seizures (petit mal)

B. Myoclonic seizures

C. Clonic seizures

D. Tonic seizures

E. Atonic seizures

F. Tonic-clonic seizures

III. Unclassified seizures which, due to inadequate data or classification

Neurology Chapter of IAP
 International League against Epilepsy
Classification of epilepsies and syndromes
I. Location-related (focal or partial) epilepsies

A. Idiopathic with an age-related onset.

 e.g. benign rolandic epilepsy

B. Symptomatic

 Very rare syndromes e.g. epilepsia partialis continua

 Syndromes. which result from seizures arising from a specific part of the
brain but which may have diverse but defined aetiologies

 temporal lobe epilepsies

 frontal lobe epilepsies

 parietal lobe epilepsies

C. Cryptogenic

 As above but no aetiology identified

II. Generalised epilepsies

A. Idiopathic

 benign neonatal convulsions

 childhood and juvenile absence epilepsy

 juvenile myoclonic epilepsy

B. Symptomatic

 early myoclonic encephalopathy

 Specific syndromes which have epilepsy as the predominant feature. e.g.

Lafora body disease

C. Cryptogenic

 Rare with a presumed but undefined aetiology, e.g. Lennox-Gastaut

syndrome

III. Undetermined, whether focal or generalised

IV. Special situations

 Includes febrile convulsions


Neurology Chapter of IAP
seizures due to metabolic upset, e.g. alcohol
 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 complexNeurology Chapter of IAP
 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

 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
 Aetiology of neonatal seizures
• Perinatal: • Infections
– HIE • Structural
– ICH abnormalities
• Metabolic • Drug withdrawal
– Hypoglycemia,
hypocalcemia
– hypomagnesemia
– Other

Neurology Chapter of IAP

 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
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
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 Neurology
bloodChapter of IAP
pressure or heart rate
 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
 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 temporalNeurology Chapter of IAP
sclerosis
 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
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 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
 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
 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
Table 1: Anticonvulsants used

Dose Daily schedule Therapeutic Indications Mechanism of action

mg/kg/day (T1/2 in hours) levels
 g/ml
Valproate 20-30 2-4 50-100 Broad spectrum Effect on Ca current
(Epilim, Convulex) (7-15)
Carbamazepine 20-25 2-3 6-12 Partial Blocks Na channels
(Tegretol) (8-24) T/C
Oxcarbazepine 20-30 2-3 13-31 Partial Blocks Na channels
(Trileptal) T/C
Phenytoin 5-8 1-2 5-20 T/C Blocks Na channels
(Epanutin) (9-40) Partial
Lamotrigine 5-10 1-2 1.5-4 Partial Inhibits release of
(Lamictan) (Less in (60 if on Generalised excitatory amino acids
combination valproate) Lennox Gastaut like glutamate
with valproate) Absence
Myoclonic
Ethosuximide 20-30 1-2 40-60 Absences Reduction of the T -
(Zarontin) (20-40) type Ca current in the
thalamic relay
neurones
Clonazepam 0.2-0.3 2-4 NA Myoclonic Enhances GABA
(Rivotril) (20-30 min) T/C mediated inhibition
Clobazam 0.5-2 1-2 NA Adjunct in myoclonic , Enhances GABA
(Urbanol) T/C and Lennox Gastaut mediated inhibition
Phenobarbitone 3-5 1-2 15-45 T/C Enhances GABA
(Lethyl) (37-73) mediated inhibition
Gabapentin 10-25 3-4 Not available Partial Irreversible blocking of
(Neurontin) (6) Generalised GABA transaminase
Vigabatrin 40-100 1-2 NA Partial Unknown
(Sabril) (4-5 days) Generalised
West syndrome
Topiramate 3-9 1-2 NA Broad spectrum NA channel blocker
(Topamax) (12-24) Enhances GABA
mediated transmission
Inhibition on AMPA
glutamate receptors
Carbonic anhydrase
inhibitor

*T: Tonic; C: Clonic; T/C: Tonic-Clonic; A: Atonic,

Neurology Chapter of IAP

 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
Step wise treatment of seizure control in Status Epilepsy (Excluding Neonates)

Step I: Benzodiazepine - Lorazepam: 0.1 mg/kg IVI at 2 mg/min

NB: Lorazepam, if available, is the drug of choice because
the anticonvulsant effect last up to 24 hours

OR

- Valium: 0.25-0.5 mg/kg IVI

Followed by

Step II: Phenytoin 20 mg/kg IVI slowly not faster than 25-50 mg/min

Seizures continuing

Step III: Phenytoin Additional 5 mg/kg

Seizures continuing

Step IV: Has to be done in ICU as ventilatory support is usually necessary

1. Thiopentone Starting infusion dose is 1-3 mg/kg/hour and one may need to
go as high as 5-7 mg/kg/hour

OR

2. Midazolam Start with a loading dose of 0.2 mg/kg IVI bolus, then at a dose
of 0.75 – 10 microgram/kg/min

OR

3. Propofol 1-2 mg/kg IVI, followed by 2-10 mg/kg/hour.

Its use in children is limited and should be used with caution.

Neurology Chapter of IAP

 Status epilepticus

– Treat the cause of the seizures

• ? LP
• CT/MRI
• Drug levels
• Toxic screen

Neurology Chapter of IAP

 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