Seizure Disorders in Children

1. Seizure Disorders in Children Dr. Pushpa Raj Sharma FCPS Professor of Child Health Institute of Medicine

2. 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

3. Definitions • Epilepsy: A condition in which an individual is predisposed to recurrent seizures because of a central nervous system disorderStatus Epilepticus: More than thirty minutes of continuous seizure activity, or recurrent seizures without intercurrent recovery of consciousness

4. 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

5. 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

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

7. 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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).

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

14. Simple partial - motor

16. 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.)

17. 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

18. 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

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

20. 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.

21. 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.)

22. 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.