Seizures in Children

Dr Penny MancaisConsultant PaediatricianDorset County Hospital

Foundation trust

To be Covered

Terminology

History taking

Prognosis of Seizures

Fits, faints and funny turns

When to refer

Pragmatic advice in Epilepsy

Definition of Seizure

ANY SUDDEN ATTACK FROM WHATEVER CAUSE.

Many manifestations determined by site of origin.

Many causes:

Non Epileptic (reflex anoxic ,fainting, Tics ,migraines, night terrors )

Epileptic

Definition of Epileptic Seizure

Manifestation of Epileptic (excessive) usually self limited activity of neurons in the brain

ILAE

Prognosis of seizures

1% afebrile seizure

50% will have a recurrence

3% febrile seizureRisk of recurrence 35%

Risk of Epilepsy following simple 1%

Risk of Epilepsy following complex 6%

Risk of Epilepsy following complex/FH 30%

Taking the History

Diagnosis is in the History

No Ix to confirm epilepsy

RELIANT ON HISTORY

What to ask

Eye witness account

Role play

Avoid interpretations

Time line

Use counting

Home videoing

Features that may occur in Seizures

Sudden fallJerking limbsBlank stareUrinary incontinenceFunny smellFeeling of fearFacial flushingSeeing coloured spotsvomiting

Racing heart

Tingling sensations

Headache

Generalised stiffening

Floppiness

Ringing noises

Hiccups

Sudden loss of vision

Fits Faints and funny turns

Collapsing with convulsions

Drop attacks

Stiffening attacks

During sleep

Fits faints and funny turns

History of Event / Attack

• Frequency

• Timing

• Triggers

• Warning beforehand

• Colour change

• Alteration in conscious level

• Motor phenomena

• Duration of attack

• Symptoms following attack

What is the trigger for the attack?

• Only during sleep?

• Related to feeding?

• With a fever?

• On initiation of movement?

• With excitement/emotion?

• Following unpleasant/painful stimuli?

• Boredom/concentration

What is the predominant motor phenomenon?

• Repetitive stereotyped spasm?

• Hypertonia?

• Hypotonia (include FALLS)?

• Dystonia?

• Unsteadiness?

• Parasomnias

• Sleep myoclonus

• Paroxysmal dystonias/dyskinesias

• GOR

• Sandifer syndrome

• Febrile convulsions

• Cataplexy

• Overflow movements

• Shuddering attacks

• Reflex anoxic seizures

• Cyanotic breath-holding attacks

• Infantile spasms

• Benign myoclonus of infancy

• Facial tics

• Focal seizure

• Behavioural stereotypes

• Hyperekplexia

• Cardiac arrhythmias

• Syncope

• Cata-plexy

• Akinetic (drop) attacks (usually only with other seizure types)

• Benign paroxysmal torticollis

• Paroxysmal dystonia / dyskinesia

• Drug reactions

• Benign paroxysmal vertigo

• Episodic ataxia

• Tumour (posterior fossa)

• Periodic paralyses

What is the colour change?

• Pallor

• Cyanosis

• Flushing

• Structural cardiac lesion

• Cyanotic breath-holding attack

• Gastro-oesophageal reflux

• Cardiac arrhythmias

• Neurocardiogenic syncope

• Reflex anoxic seizures

• Self gratification behaviour

OLDER CHILD• Cardiac arrhytthmias

• Neurocardiogenic syncope

• Reflex anoxic seizures

• Neurocardiogenic syncope

• Hyperexplexia

• Myoclonus

• TICs

• Paroxysmal dyskinesias

• Benign paroxysmal vertigo/torticollis

• Migraine

• Eye movement disorders

• Episodic ataxia

• Cataplexy

• Akinetic (drop) attacks

• Day dreams

• Hyperventilation panic/anxiety attacks

• Non epileptic attack disorder

• Pseudo-syncope or psychogenic syncope

• Stereotypes/ritualistic behaviour (eg. Children with learning difficulties)

• Confusional arousal

• REM sleep disorders

• Night terrors

TODDLER• Cardiac arrhytthmias

• Reflex anoxic seizures

• Cyanotic breath-holding attacks

• Hyperekplexia

• Myoclonus

• Paroxysmal dyskinesias

• Sandifer syndrome

• Benign paroxysmal vertigo/torticollis

• Migraine

• Cataplexy

• Akinetic (drop) attacks

• (Febrile convulsions)

• Overflow movements

• Self gratification behaviour

• Stereotypies/ritualistic behaviour (eg. Children with learning difficulties)

• Head banging

• Confusional arousal

• Night terrors

INFANT• Cardiac arrhytthmias

• Hyperexplexia

• Structural cardiac lesion

• Benign myoclonus of infancy

• Paroxysmal dystonia

• Sandifers syndrome/GOR

• Benign paroxysmal torticollis

• Alternating hemiplegia

• (Infantile spasms)

• Self gratification behaviour

• Shuddering attacks

• Benign sleep myoclonus

•Daydreaming

When to refer

Any child with ‘unexplained seizure’ (NICE)

<1years discuss ?admit

NO investigations

Advise home videoing, diary monitoring

All children with a diagnosis of epilepsy should have a named paediatrician.

Pragmatic advice in EpilepsyWill my child die?

Risk from fit is negligible

SUDEP 1:200 (poor control,teenagers,male)

Accidents

NO climbing/harness, swimming 1:1, showerAlcohol (1=3 on anticonvulsants)Recreational drugs (increase risk of seizure)

Advice continued

Contraception:Higher doses of Oestrogen for enzyme

inducing drugs plus barrier protection

Starting a family

DrivingNocturnal seizures okFit free 1yr on/off medicationDVLA latest advice

Medication

Now 17 drugs available

Aim to improve seizure control

Minimises effects on learning and behaviour

Blood tests not needed

Summary

History, History, History

All children with unexplained seizure need referral

<1 pick up phone ? Admit

Web sites:National Society for Epilepsy

Epilepsy action