Pediatric Seizures

Introduction

Laboratory and other studies

Treatment Options

History

Differential diagnosis

Anticonvulsants

Physical exam

Management

Summary

Introduction

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).

History

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.

Physical exam

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 and other studies

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.

Differential diagnosis

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.

Management

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).

Commonly Used Anticonvulsants

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.

Summary

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.

Reviewed by CDR Wendy Bailey, MC, USN, Pediatric Specialty Leader, Naval Medical Center San Diego, San Diego, CA (1999).

Preface  ·  Administrative Section  ·  Clinical Section

The General Medical Officer Manual , NAVMEDPUB 5134, January 1, 2000
Bureau of Medicine and Surgery, Department of the Navy, 2300 E Street NW, Washington, D.C., 20372-5300

This web version of The General Medical Officer Manual, NAVMEDPUB 5134 is provided by The Brookside Associates Medical Education Division.  It contains original contents from the official US Navy version, but has been reformatted for web access and includes advertising and links that were not present in the original version. This web version has not been approved by the Department of the Navy or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense. All material in this version is unclassified. This formatting © 2006 Medical Education Division, Brookside Associates, Ltd. All rights reserved.

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