Pediatric Seizures

Department of the Navy
Bureau of Medicine and Surgery

Seizures are episodic, involuntary, and recurring alterations of brain function that affect motor activity, behavior, sensation, or autonomic function. Studies show that approximately 1-2 percent of the general pediatric population is affected by recurring non-febrile convulsions. Nearly, 2-5 percent of patients between the ages of 6 months and 6 years have febrile seizures. A febrile seizure is defined as convulsions associated with elevated temperatures in patients without evidence of intracranial infection or other defined causes. The International Classification of Seizures divides seizures into two types, based on electrical activity in the brain: partial (seizure beginning locally); and generalized (seizures without local onset and involving all parts of the cortex simultaneously).

Given a child who has just experienced an initial or recurrent seizure, the following important historical information should be obtained:

• How the event began.

• Whether there were any precipitating events (including trauma).

• What actually happened during the event?

• What was the duration of the event?

• Has the child been ill (meningitis)?

• Prenatal, perinatal, and developmental history.

• Personal history of seizures.

• Family history of seizures.

• Medications the patient had been taking for his or her seizure disorder.

The patient who presents with a history of new or recurring seizures needs a complete general and neurodevelopmental physical examination. Measure and plot the head circumference (there are standard charts for head growth to 18 years of age). Always examine fundi (hemorrhage). On neurological examination, evaluate for any focal deficit. Observe for asymmetry of gait, arm swing, or imbalance. Ask the patient about any changes in mental abilities or personality. Examine the skin closely for evidence of hypopigmented patches or other signs of a neurocutaneous syndrome. The hypopigmented macules of tuberous sclerosis can sometimes only be seen with a Wood's lamp.

Laboratory studies include a complete blood count, urinalysis, and serum electrolytes, calcium, magnesium, phosphorus, protein, and blood sugar. If the patient is a small infant (< 3 months), is febrile, or shows other signs of a central nervous system (CNS) infection, do a lumbar puncture (LP), including a cell count, glucose, protein, a gram stain, and culture of the CSF. If there is clinical evidence of increased intracranial pressure, obtain a CT scan before the LP. An imaging procedure (CT scan or MRI study of the brain) is a necessary part of the evaluation for seizures. An EEG is essential. Also consider a toxicological screen.

There is a large spectrum of disorders that present in a fashion similar to seizures. The differential diagnoses include breath-holding spells, syncope, sleep disorders (such as night terrors), benign paroxysmal vertigo, and pseudoseizures. A large part of ruling out these nonepileptiform disorders will depend on the history obtained.

Consider admitting patients with first seizures of unknown etiology for evaluation and sometimes for treatment, as well as in response to parental anxiety. If the seizure was a classic episode for a patient with a chronic seizure history that is on a subtherapeutic drug regimen, he or she can probably be discharged after the seizure medications are adjusted and follow-up is arranged. Patients with febrile seizures can probably be discharged if no underlying life-threatening infection (e.g., meningitis, shigella) is detected, although many are admitted overnight for parental support. All patients with complex recurrent seizures should be referred to a neurologist.

Treatment Options

Treatment varies with clinical presentation. New or recurrent generalized or partial seizures should be treated only after the clinician is confident that the patient has a disorder that requires treatment. Most neurologists will not prescribe anticonvulsant medication to a patient after a first or even a second idiopathic (and afebrile) seizure. Even now we don't have the perfect anticonvulsant, which would absolutely prevent seizures and have absolutely no adverse effects. Treatment with these medications is often worse than the underlying condition. Also, the decision to treat implies a commitment to at least 2 full years of medication as well as the potential limitation of personal activities, employment, and driving privileges (teenagers).

These are included for information purposes only.

• Carbamazipine (Tegretol): up to 25 mg/kg/day divided TID or QID with therapeutic blood levels of 4-12 ug/ml; side effects include nausea, anorexia, drowsiness, visual disturbances, ataxia, leukopenia, aplastic anemia, agranulocytosis.

• Valproic acid (Depakene): 15-60 mg/kg/day divided TID with therapeutic blood levels of 40-100 ug/ml (occasionally up to a trough level of 120); side effects include behavioral changes, interference with cognition, rash.

• Phenytoin (Dilantin): 4-8 mg/kg/day divided BID-TID with therapeutic blood levels of 10-20 ug/ml; side effects include gingival hyperplasia, dermatitis, hirsutism, lymphadenopathy, megaloblastic anemia, leukopenia, pulmonary fibrosis, hepatitis.

In general you should always obtain a consultation on patients presenting with new-onset seizure disorder. The urgency of the consultation depends on the severity of the seizure event and the complexity of the historical and laboratory evaluation.