Seizures in Children

Dr Penny Mancais Consultant Paediatrician Dorset 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 seizure
Risk 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 fall Jerking limbs Blank stare Urinary incontinence Funny smell Feeling of fear Facial flushing Seeing coloured spots vomiting 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

INFANT
Parasomnias Sleep myoclonus GOR Sandifer syndrome Febrile convulsions Paroxysmal dystonias/dyskinesias Cataplexy Overflow movements Shuddering attacks Reflex anoxic seizures Cyanotic breath-holding attacks Daydreaming Cardiac arrhythmias Neurocardiogenic syncope Reflex anoxic seizures Structural cardiac lesion Cyanotic breath-holding attack Gastro-oesophageal reflux Self gratification behaviour Infantile spasms Benign myoclonus of infancy Facial tics Focal seizure Behavioural stereotypes
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

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

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

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 colour change?

Pallor Cyanosis Flushing

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

What is the predominant motor phenomenon?

Repetitive stereotyped spasm? Hypertonia? Hypotonia (include FALLS)? Dystonia? Unsteadiness?

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

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 Epilepsy

Will my child die?

Risk from fit is negligible

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

NO climbing/harness, swimming 1:1, shower Alcohol (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

Driving
Nocturnal seizures ok Fit free 1yr on/off medication DVLA 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