Seizures in Children

Question 1

What is the definition of seizure?

Answer 1

Episodic neurological phenomena which are excessive, hypersynchrnous activity of neurons in the cerebral cortex.

Question 2

Talk through the Epidemiology of Seizures in Children.

Answer 2

• 5% kids will have a seizure - more common than adults
  
  • 3% of these are febrile convulsions (most) - genetic predisposition (type of epilepsy but not included in with the s word). Grow out of them and no harm.
  • approx 1% Acute symptomatic seizures - e.g. meningitis, trauma, hypoglycemia (reversible problem)
  • approx 1% Single / recurrent unprovoked seizures = epilepsy
• Epileptic seizures
  
  • Recurrence after first afebrile seizures
  • 1/3 over 2y
  • 50% of those in first 6mo

Question 3

What are the differences between focal seizures vs generalised seizures?

Answer 3

Generalised:

• start all over the brain - 3Hz spike wave (CAE)
• Types: distinct electrochemically
  
  • tonic-clonic
  • absence
  • myoclonic
  • tonic
  • atonic
  • spasms
• automatisms - specific movements (common in temporal, unconsiousness)

Focal (partial - part of brain, no longer used)

• start in one part of the brain - specific area
• can become secondary generalised
• types: (not biological, but clinical symptomatic)
  
  • motor
  • somatosensory
  • visual/auditory
  • autonomic
  • dysphasic
  • dyscognitive (only have impaired conciousness if it involved the part of the brain for conciousness)
• aura = automatically focal

determine with EEG and history

Question 4

What are some important differentials for epilepsy in children?

Answer 4

• Normal phenomena
  
  • sleep jerks
  • tantrums
  • inattention
• Syncope/vasovagal/long QT
  
  • stretch syncope
  • context
  • breath holding spells - baby fainting
• Parasomnias
  
  • narcolepsy cataplexy
  • confusional arousal
  • night terrors
  • sleep walking
• Migraine variants/neurovascular events
  
  • Cx migraine
  • BPPV
  • TIA
• movement disorder
• psychiatric disturbance (psychogenic seizures).
  
  • usually women

Question 5

Talk through the classification of epilepsy in children

Answer 5

Definition:

Recurrent unprovoked (afebrile) seizures (2 or more). Epileptic seizures.

Excludes a number of other seizures:

• acute symptomatic are not epilepsy,
• febrile are taken out,
• neonates are taken out.

Lots of types, too many to learn, 2 broad classes with 4 classifications.

1. Idiopathic (genetic predisposition) - good brain type
   
   • genetic generalised epilepsies
   • benign focal epilepsies
2. Symptomatic (underlying metabolic/genetic disorder/lesion) - bad brain type (underlying problem that is tangible)
   
   • symptomatic generalised epilepsies - encephalopathies
   • symptomatic (lesional) focal epilepsies

Question 6

What is the management of a child with seizures?

Answer 6

• Workup:
  
  • history
    
    • perinatal
    • history of minor events
    • FHx
    • developmental history
  • exam
    
    • ICP
    • meningism
    • concious state
    • dysmorphic features
  • Ix
    
    • biochem
    • MRI - only if recurrent
    • EEG,
    • genetic
    • possible MRI
  • Treatment:
    
    • counsel
    • avoid precipitating (sleep deprivation, hyperventilation, flashing lights)
    • lifestyle precautions (swimming, driving, alcohol, heights)
    • antiepileptic drug therapy if indicated
    • treatment for uncontrolled epilepsies (ketogenic diet, rectal diazepam, etc…)

Question 7

What are the age groups, symptoms and signs of someone with a febrile convulsion?

Answer 7

• 6mths to 6 years of age.
  
  • <6mths rule out serious cause (meningitis).
• 3% of healthy children (common)
• Associated with viral infections and fever
• Simple vs complex:
  
  • Simple (tonic clonic <15mins don’t recur in same illness,
  • Complex: odd beginning (focal signs), odd middle (longer than 15), odd end (incomplete recovery in 1 hr), odd again (have 2 in one illness)

Question 8

What are some reasons for epilepsy deterioration?

Answer 8

• metabolic disturbance (BSL)
• fever/infection
• trauma
• trigger e.g. flashing lights
• alcohol/drugs
• sleep deprivation
• adherence to medications

Question 9

A girl come in because she’s worried her carbemazepine is causing acne and doesn’t want to take it, what do you do?

Answer 9

• Carbemazepine is a 1st line drug for focal seizures - Na+ blocker. SE = ataxia, drowsiness and agranulocytosis
• its important to take the medication but we can treat the acne.
• comedolytics - 3-6mths treatment
  
  • sialic acid
  • retinoids (teratogenic, LFTs, CI in pregnancy or high lipids)
• anti-androgens
  
  • OCP - carbemazepine can decrease its effectiveness
  • spironolactone - CI in pregnancy
• antibacterial
  
  • benzoyl peroxide (tpical)

Question 10

What is the advice for a teenager who wants a learner’s permit for driving but has epilepsy?

Answer 10

• A conditional liscense may be granted:
  
  • with chronic epilepsy you need a seizure free period of 2 years. A shorter period only on recommendation from consultant with clear seizure control.
  • with a 6mth period for recently diagnosed epilepsy