Seizure Disorders in Children epilepsy by mikeholy


									Seizure Disorders in Children

    Dr. Pushpa Raj Sharma FCPS
    Professor of Child Health
    Institute of Medicine

   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

   Epilepsy: A condition in which an individual
    is predisposed to recurrent seizures because
    of a central nervous system disorder

    Status Epilepticus: More than thirty minutes
    of continuous seizure activity, or recurrent
    seizures without intercurrent recovery of
   No data available in Nepal.
   Seizure disorders: 360/100,000 (India, Saha SP
   Prevalence of seizure disorder in children has
    been reported to be 350/100,000 (Gortmaker
    and Sappenfield, 1984). However, 3-5% of all
    children will have one or more seizures
    (Haslem, 2000). The incidence of epilepsy (new
    cases per year) has been reported to be
    50/100,000, with 75% of people developing
    epilepsy doing so prior to 20 years of age
    (Holmes, 1992)
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
Recurrent seizures during fever in an 24
month old
   History
   A 24 month old boy was seen in the KCH emergency room following a
    seizure accompanied by fever, his second in 6 months. The child had
    been well until the previous day, when parents notices fever for which he
    was take to a doctor who prescribed amoxicillin for the diagnosis of
   The following morning, the boy experienced a 2 minute generalized
    stiffness just as father was administering amoxicillin. Afterwards, he was
    rushed to the KCH.The child resumed normal alertness on way to the
   Prior seizures had occurred at the ages of 18 and 20, months with fever
    in each instance. Prior seizures were otherwise identical in duration and
   Past medical history was noncontributory. Development was normal, with
    independent walking at 12 months and present use of single sentences.
    Review of family history revealed that an older sister had suffered from
    similar seizures during fever until age 3.
Recurrent seizures during fever in an
24 month old
   Physical Exam
   In the emergency room, the boy was alert and
    appeared only minimally ill. Temperature was 38.4.
    General physical exam revealed a dull and
    erythematous left tympanic membrane and mild
    cervical adenopathy. No nuchal rigidity or other
    meningeal signs were apparent.
   Neurologic examination was entirely nonfocal and
    the child's motor skills, language, and social
    interaction seemed normal for age.
 • Mode  of onset of convulsion, character,
 duration, any similar previous history
 • Triggering factors- fever, toxic substance or
 drug, metabolic dis- turbance.
 • Family history of convulsion, inborn error of
 • Peri-natal/Natal history-birth asphyxia,
 jaundice, birth trauma, central nervous system
 (CNS) infection e.g. meningitis, encephalitis
 • CNS status-cerebral palsy, mental retardation
 (learning difficulty), any post-convulsive state.

 A) Acute/Non-recurring
   (i) with fever: febrile convulsion, infections e.g.
 meningitis, encef)halitis. .
   (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.
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.
Atypical febrile seizures

   The duration is longer than 15 min.
   Repeated convulsions occur within the same
   Focal seizure activity or focal findings are
    present during the postictal period.
    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).
Classification of Epileptic Seizures

   Partial seizures:
       Simple partial (consciousness retained)




       Complex partial (consciousness impaired)
         Simplepartial, followed by impaired consciousness
         Consciousness impaired at onset

       Partial seizures with secondary generalization

Source: Nelson”s Textbook of Pediatrics, (17th ed.)
Classification of Epileptic Seizures
   Generalized seizures
       Absencess
           Typical
           Atypical
       Generalized tonic clonic
       Tonic
       Clonic
       Myoclonic
       Atonic
       Infantile spasms
   Unclassified seizures
            Source: Nelson”s Textbook of Pediatrics, (17th ed.)
Mimicking seizures
   Benign paroxysmal vertigo
   Night terrors
   Breath-holding spells
   Syncope
   Paroxysmal kinesigenic Choreoathetosis
   Shuddering attacks
   Benign paroxysmal torticollis of infancy
   Hereditary chin trembling
   Narcolepsy
   Rage attacks
   Pseudo seizures
   Masturbation
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
   History.
   The relationship between the neurologic outcome
    and the duration of status epilepticus is unknown in
Treatment of status epilepticus

   Initial treatment:
       assessment of the respiratory and cardiovascular
       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.)
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.

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