Epilepsy in Children Flashcards
What is epilepsy?
Epilepsy is an umbrella term for a condition where there is a tendency to have seizures. Seizures are transient episodes of abnormal electrical activity in the brain. There are many different types of seizure.
A diagnosis of epilepsy is made by a specialist based on the characteristics of the seizure episodes.
What are generalised tonic-clonic seizures?
Management?
These are what most people think of with an epileptic seizure. There is loss of consciousness and tonic (muscle tensing) and clonic (muscle jerking) movements. Typically the tonic phase comes before the clonic phase. There may be associated tongue biting, incontinence, groaning and irregular breathing.
After the seizure there is a prolonged post-ictal period where the person is confused, drowsy and feels irritable or low.
Management of tonic-clonic seizures is with:
First line: sodium valproate
Second line: lamotrigine or carbamazepine
What are focal seizures?
S/s?
Tx?
Focal seizures start in the temporal lobes. They affect hearing, speech, memory and emotions. There are various ways that focal seizures can present:
Hallucinations
Memory flashbacks
Déjà vu
Doing strange things on autopilot
One way to remember the treatment is that the choice of medication is the reverse of tonic-clonic seizures:
First line: carbamazepine or lamotrigine
Second line: sodium valproate or levetiracetam
Absence seizures?
Tx?
Absence seizures typically happen in children. The patient becomes blank, stares into space and then abruptly returns to normal. During the episode they are unaware of their surroundings and won’t respond. These typically only lasts 10 to 20 seconds. Most patients (more than 90%) stop having absence seizures as they get older.
Management is:
First line: sodium valproate or ethosuximide
Atonic seizures?
Tx?
Atonic seizures are also known as drop attacks. They are characterised by brief lapses in muscle tone. These don’t usually last more than 3 minutes. They typically begin in childhood. They may be indicative of Lennox-Gastaut syndrome. Management is:
First line: sodium valproate
Second line: lamotrigine
Myoclonic seizures?
Tx?
Myoclonic seizures present as sudden brief muscle contractions, like a sudden “jump”. The patient usually remains awake during the episode. They occur in various forms of epilepsy but typically happen in children as part of juvenile myoclonic epilepsy.
Management is:
First line: sodium valproate
Other options: lamotrigine, levetiracetam or topiramate
Infantile spasms?
Management?
This is also known as West syndrome. It is a rare (1 in 4000) disorder starting in infancy at around 6 months of age. It is characterised by clusters of full body spasms. There is a poor prognosis: 1/3 die by age 25, however 1/3 are seizure free.
It can be difficult to treat but first line treatments are:
Prednisolone
Vigabatrin
Febrile convulsions?
Consequences?
Febrile convulsions are seizures that occur in children whilst they have a fever. They are not caused by epilepsy or other underlying neurological pathology (such as meningitis or tumours). By definition, febrile convulsions occur only in children between the ages of 6 months and 5 years. Febrile convulsions do not usually cause any lasting damage. One in three will have another febrile convulsion. Having febrile convulsions slightly increases the risk of developing epilepsy in the future.
Investigations for epilepsy?
A good history is the key to a diagnosis of epilepsy. It is important to establish that any episodes were seizures, as opposed to vasovagal episodes or febrile convulsions. Try to identify the type of seizure. Patients with a clear history of a febrile convulsion or vasovagal episode do not require further investigations.
An electroencephalogram (EEG) can show typical patterns in different forms of epilepsy and support the diagnosis. Perform an EEG after the second simple tonic-clonic seizure. Children are allowed one simple seizure before being investigated for epilepsy.
An MRI brain can be used to visualise the structure of the brain. It is used to diagnose structural problems that may be associated with seizures and other pathology such as tumours. It should be considered when:
The first seizure is in children under 2 years
Focal seizures
There is no response to first line anti-epileptic medications
Additional investigations can be considered to exclude other pathology that may cause seizures:
ECG to exclude problems in the heart.
Blood electrolytes including sodium, potassium, calcium and magnesium
Blood glucose for hypoglycaemia and diabetes
Blood cultures, urine cultures and lumbar puncture where sepsis, encephalitis or meningitis is suspected
General advice to give to patients and families with seizures?
Patients and families presenting with seizures need to be given advice about safety precautions, recognising, managing and reporting further seizures. It is important to avoid situations where a seizure may put the child in danger, with advice to:
Take showers rather than baths
Be very cautious with swimming unless seizures are well controlled and they are closely supervised
Be cautious with heights
Be cautious with traffic
Be cautious with any heavy, hot or electrical equipment
Older teenagers with epilepsy will need to avoid driving unless they meet specific criteria regarding control of their epilepsy. These rules change frequently so it is always worth looking them up if advising patients.
Anti-epileptic drugs?
Side effects of each?
There are a number of maintenance anti-epileptic drugs that work by raising the seizure threshold and reducing the likelihood of the patient having a seizure. These will be initiated, monitored and titrated by a paediatric specialist with expertise in epilepsy.
Sodium Valproate
This is a first line option for most forms of epilepsy (except focal seizures). It works by increasing the activity of GABA, which has a relaxing effect on the brain. Notable side effects of sodium valproate include:
Teratogenic, so patients need careful advice about contraception
Liver damage and hepatitis
Hair loss
Tremor
There are a lot of warning about the teratogenic effects of sodium valproate and NICE updated their guidelines in 2018 to reflect this. It must be avoided in girls unless there are no suitable alternatives and strict criteria are met to ensure they do not get pregnant.
Carbamazepine
This is first line for focal seizures. Notable side effects are:
Agranulocytosis
Aplastic anaemia
Induces the P450 system so there are many drug interactions
Phenytoin
Notable side effects:
Folate and vitamin D deficiency
Megaloblastic anaemia (folate deficiency)
Osteomalacia (vitamin D deficiency)
Ethosuximide
Notable side effects:
Night terrors
Rashes
Lamotrigine
Notable side effects:
Stevens-Johnson syndrome or DRESS syndrome. These are life threatening skin rashes.
Leukopenia
Management of seizures in community?
Put the patient in a safe position (e.g. on a carpeted floor)
Place in the recovery position if possible
Put something soft under their head to protect against head injury
Remove obstacles that could lead to injury
Make a note of the time at the start and end of the seizure
Call an ambulance if lasting more than 5 minutes or this is their first seizure.
What is status epilepticus?
Status epilepticus is an important condition you need to be aware of and how to treat. It is a medical emergency.
It is defined as a seizure lasting more than 5 minutes or 2 or more seizures without regaining consciousness in the interim.
Management of status epilepticus?
Management of status epileptics in the hospital (take an ABCDE approach):
Secure the airway
Give high-concentration oxygen
Assess cardiac and respiratory function
Check blood glucose levels
Gain intravenous access (insert a cannula)
IV lorazepam, repeated after 10 minutes if the seizure continues
If the seizures persist the final step is an infusion of IV phenobarbital or phenytoin. At this point intubation and ventilation to secure the airway needs to be considered, along with transfer to the intensive care unit if appropriate.
Medical options in the community:
Buccal midazolam
Rectal diazepam
Benign rolandic epilepsy?
Features?
Benign rolandic epilepsy is the most common epilepsy syndrome in childhood. It peaks at age 8-9 and stops in the teenage years, hence why it is called benign. Seizures are typically infrequent, focal, single seizures. Symptoms typically begin in the face and include facial twitching, numbness, drooling or difficulty speaking. The child remains aware, although in some cases the seizures then generalise. The seizures typically occur at night.
