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CONVULSIONS IN CHILDREN

Dr. M. Subramanian, Professor


Dr. K. Karthikeyan, Assistant Professor
Rajah Muthiah Medical College & Hospital, Annamalai University

Definition
Sudden paroxysmal electrical discharge from the Central
nervous system resulting in involuntary, motor, sensory (or)
autonomic disturbances with (or) without alteration in
sensorium.
Seizure: the clinical manifestation of an abnormal and
excessive excitation and synchronization of a population of
cortical neurons
Epilepsy: two or more recurrent seizures unprovoked by
systemic or acute neurologic insults

Etiology

INFECTIONS OF THE CNS

Acquired bacterial meningitis, TB meningitis, aseptic meningitis,


encephalitis, cerebral malaria, tetanus, mumps,
encephalopathy, measles encephalopathy and Reyes
syndrome.
Intrauterine infections

Post infectious (or) post vaccinal encephalopathy


Following measles infection subacute sclerosing
panenceplatis, Post whooping cough encephalopathy and
chickenpox encephalopathy

Etiology Contd..

METABOLIC CAUSES
Dehydration, dyselectrolytemia, acidosis, alkalosis, and
Hypoglycemia, Hyperglycemia, and inborn errors of
metabolism.

SPACE OCCUPYING LESIONS


Neoplasm of brain, Brain abscess, Tuberculoma, Cysticercosis.
VASCULAR
Arteriovenous malformations, Intracranial Thrombosis (or)
Haemorrhage and Consumptive Coagulopathies. Congenital
Malformations, Migration defects, trauma.

Etiology Contd..
MISCELLANOUS CAUSES
Anoxic / Hypoxic Ischemic Encephalopathy stage II,

Residua of birth trauma and birth asphyxia, heat stroke,


acute brain swelling, poisoning, lead encephalopathy,
Hypertensive encephalopathy, breath holding spells,
grey matter degeneration, and storage disorders.

DRUGS AND POISONS


Toxic doses of Phenothiazine, Salicylate,

Diphenylhydantoin, Strychnine, Carbon monoxide,


dapsone.

Neonatal Seizures
In Neonates, incomplete myelination, lack of neurotransmitter, poor
spread of epileptiform discharge and lack of brain maturation result
in atypical and poorly organised seizures.
Observation of abnormal, repetitive attacks of movements,
postures or behaviors

Classification
subtle
tonic
clonic
myoclonic
autonomic
Evaluation for cause(s) of seizures
Confirmation/support by EEG

Etiology
Hypoxic ischemic encephalopathy, birth trauma
Intracranial Heamorrhage.
Metabolic Hypoglycemia, Hypocalcemia, Hypomagnesemia,
Hyponatremia
Pyridoxine dependency and deficiency
Inborn errors of metabolism - of aminoacids, carbohydrate,
organic acids and deficiency of enzymes (Urea cycle)
Structural malformations
Infections - Bacterial meningitis, intrauterine infections, brain
abscess, septicaemia
Drug withdrawal Sedatives, Anticonvulsants, narcotics
Genetic / Familial
Miscellaneous / Idiopathic

Acute Management Of Neonatal Seizure


Step 1. Stabilize the vital functions
Step 2. Correct transient metabolic disturbance
Hypoglycemia, Hypocalcemia & Hypomagnesemia.
Step 3. Phenobarbital 20 mg/kg iv load, 5mg/kg iv (may repeat
to total dose of 40mg/kg), consider EEG monitoring,
ventilation
Step 4. Lorazepam 0.05mg/kg iv (may repeat to total dose
of 0.1mg/kg),

Acute Management Of Neonatal Seizure


Contd..
Step 5. Phenytoin 20mg/kg slow iv load, 5mg/kg iv
(may repeat to total dose of 30mg/kg),
Step 6. Pyridoxine 50-100mg/kg (with EEG
monitoring)
Step 7. Other agents- Lignocaine 4-6mg/kg/hr,
Midazolam 0.06-0.4mg/kg/hr

Seizures Of Infancy Of Childhood


Commonly Include

Febrile convulsions
Infantile spasms
Age dependent epileptic syndromes
Seizures due to other causes

Febrile Seizures
Definition - Convulsion associated with fever of extra cranial
origin in infant and children in the age group of 6 months to
5 years
Age dependent imbalance between the convulsant and
anti convulsant system in the brain.
More common in between 6 months & 5 years
Peaks in 14 18 months
90% occurs before 3 years
5% occurs < 6 months or > 4 years

Etiology

Respiratory tract infection Upper / Lower


Gastro intestinal tract infection
Genito Urinary tract infection
Organisms
Viral
Rota, para influenza

Bacteria
Shigella, salmonella, pnemococci

Genetics

Positive family history


Autosomal dominant inheritance pattern
Chromosome 19 p & 8 q, 13 21
Monozygotic twin - 80% common

Incidence
General
2 5 % children
More common in Japan 7 8%

Sex
more common in males than in females

Seasonal
Winter (RTI)
Summer (GIT infections)

Clinical Features Simple / Typical

More common 85%


Temp - > 39 C
Convulsions develop within 24 hrs of fever
Generalized, tonic clonic
Last for few seconds to few minutes (<15 min)
No postictal drowsiness
CNS - Normal

Clinical Features Complex / Atypical

15%
Focal or Unilateral
Last for > 15 mins
Postictal drowsiness / neurological deficit

Investigations
To find out the causes of
fever

CBC
Urine routine
Stool routine
Mx
Chest Skiagram
Blood culture
Peripheral smear

To rule out metabolic


causes

Blood sugar
Calcium
Magnesium
Electrolytes

Indications for Lumbar puncture


1st episode of febrile convulsions < 12 months
Complex febrile seizures
Focal, > 15 min

Abnormal neurological findings


Signs of meningeal irritation lethargy, irritability

Investigations Contd..
EEG
Not necessary in a case of 1st febrile seizures
Indication recurrent / atypical febrile seizures
1/3rd of cases show posterior slow wave activity

CT
MRI to rule out CNS infections

Criteria of Hospitalization
Age < 18 months
Child is ill looking
Complex seizures

Treatment - Supportive measures

Airway
Breathing
Circulation
Drugs Antipyretic
Tepid sponging
Diazepam 0.2 0.5 mg / kg / dose iv stat or rectal

Treatment Prophylaxis
Intermittent
Oral diazepam 0.2 0.4 mg /kg/dose, tds, for 3 days

Continuous

Indication recurrence of febrile convulsions


Phenobarbitone 3 5 mg / kg / day, bd,
Side effects hyper active & aggressive behavior
Sodium valproate 10 20 mg / kg / day, bd
Side effects hepato toxicity
This have to be given for 2 seizure free years

Treatment Prevention
Parent counseling parents more aware
During immunization give antipyretic if fever occurs

Risk factors
Recurrent febrile fits

Age of onset < 1yr


High temp
Duration of fever
Family H/o of febrile
seizures & epilepsy

Subsequent epilepsy

Neuro developmental delay


Complex fits
Multiple fits with in 24 hrs
Family H/o epilepsy

Prognosis
Excellent
Incidence of epilepsy in febrile seizures
With risk factor 9 %
without risk factor 1 %

Febrile Seizure
History duration of fever, &
seizures, description of episode,
family history

Invest glucose, Ca, CSF,


Electrolytes, EEG

Exam neurological &


developmental

Normal - CSF

Abnormal CSF

Meningitis, Encephalitis

Contd..

Normal CSF
Assess Risk factors

Atypical FS, Abnormal CNS finding

Typical FS, normal CNS

Observe
Start Phenobarbitone

Side effects +

Sodium Valproate

Recurrence

No Side effects

Continue 2 seizure
free years

Early
Phenobarbitone

None

Observe

Classification Of Childhood Seizures


Childhood epilepsy can be classified as:Generalized and Partial seizures
Simple and Complex
Generalized Epilepsy
1. Tonic Clonic
2. Tonic
3. Clonic
4. Absence
5. Petitmal
6. Atonic
7. Akinetic
8. Bilateral epileptic myoclonus

Partial Seizures
Simple
Complex
Secondary generalized

Simple Partial Seizure Sub


Classification
With motor signs
With somatosensory or special sensory symptoms
With autonomic symptoms or signs
With psychic symptoms (disturbance of higher cerebral
function)

Choosing Antiepileptic Drugs


Seizure type
Epilepsy syndrome
Pharmacokinetic profile
Interactions/other medical conditions
Efficacy
Expected adverse effects
Cost

AED for Partial onset seizures


Carbamazepine

Phenytoin

Felbamate

Primidone

Gabapentin

Tiagabine

Lamotrigine

Topiramate

Levetiracetam

Valproate

Oxcarbazepine

Zonisamide

Phenobarbital

AED for Absence seizures


Ethosuximide
Lamotrigine
Levetiracetam
Topiramate
Valproate
Zonisamide

AED for myoclonic seizures

Clonazapam
Lamotrigine
Levetiracetam
Topiramate
Valproate
Zonisamide

AED for Tonic Clonic seizures

Carbamazepine
Felbamate
Lamotrigine
Levetiracetam
Oxcarbazepine

Phenytoin
Topiramate
Valproate
Zonisamide

Discontinuing AEDs
Seizure freedom for 2 years
implies overall >60% chance of successful withdrawal in
some epilepsy syndromes
Favorable factors

Control achieved easily on one drug at low dose


No previous unsuccessful attempts at withdrawal
Normal neurologic exam and EEG
Primary generalized seizures except JME
Benign syndrome

Consider relative risks/benefits (e.g., driving, pregnancy)

Non-Drug Treatment / Lifestyle


Modifications
Adequate sleep
Avoidance of alcohol, stimulants, etc.
Avoidance of known precipitants
Stress reduction specific techniques

Surgical Treatment
Potentially curative
Resection of epileptogenic region (focus) avoiding
significant new neurologic deficit

Palliative
Partial resection of epileptogenic region
Disconnection procedure to prevent seizure spread
corpus callosotomy
Multiple subpial transection

Differential Diagnosis of Non-epileptic


Events

Syncope
Migraine
Cerebral ischemia
Movement disorder
Sleep disorder
Metabolic disturbance
Psychiatric disturbance
Breath-holding spells

Status Epilepticus - Definition


More than 30 minutes of continuous seizure activity
Or
Two or more sequential seizures spanning this period
without full recovery between seizures

Treatment
Time post onset

Treatment

Onset

Ensure adequate ventilation/O2

2-3 min

IV line with NS, rapid assessment, blood draw

4-5 min

Lorazepam 4 mg (0.1 mg/kg) or diazepam 10 mg


(0.2 mg/kg) over 2 minutes via second IV line or
rectal diazepam

7-8 min

Thiamine 100 mg, 50% glucose 25 mg IV


Phenytoin or fosphenytoin 20 mg/kg IV (phenytoin
PE) at 50 mg/per minute phenytoin or 150 mg
per minute fosphenytoin ( 0.75 mg/kg/min)
Pyridoxine 100-200 mg IV in children under 18
months

Treatment Contd..
Time post onset
Treatment
10 min
Can repeat lorazepam or diazepam if
seizures ongoing
30-60 min

EEG monitoring unless status ended


and patient waking up

40 min

Phenobarbital 20 mg/kg at 5 mg per


minute (0.75 mg/kg per minute)

Refractory seizures
I.V. Valproic Acid -10-20mg/kg with N. saline over
3-5
Thiopentone* - 3-5mg/kg loading.
1mg/kg/hr infusion ,increased
Propofol* - 3-5mg/kg loading,
-5-10mg/kg/hr.
* Ventilation mandatory

Thank you

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