Afebrile seizures

Febrile seizures for comparison:

  1. There is neither clinical nor laboratory evidence of an infective process directly involving the CNS

  2. The temperature is 38 degrees Celsius or higher, in a child who has not had convulsions in the absence of fever

  3. Onset is between 3 months and 6 years of age

Non-epileptic = differential of 'funny turns' in children. I.e. present with collapse

Epileptic

Treating convulsive status epilepticus in children (defined as generalised >30m or repeated tonic-clonic over 30mins with no recovery. Start treating as if STATUS if fitting for >5 minutes to prevent status:


Treating convulsive status epilepticus


Time 0 mins (1st step)


  • Seizure starts
  • Check ABC, high flow O2 if available
  • Check blood glucose
  • Confirm clinically that it is an epileptic seizure

5 mins (2nd step)

  • Midazolam 0.5 mg/kg buccally
    or
  • Lorazepam 0.1 mg/kg if intravenous access established
    Midazolam may be given by parents, carers or ambulance crew in non-hospital setting

15 mins (3rd step)

  • Lorazepam 0.1 mg/kg intravenously
    This step should be in hospital
    Call for senior help
    Start to prepare phenytoin for 4th step
    Re-confirm it is an epileptic seizure

25 mins (4th step)

  • Phenytoin 20 mg/kg by intravenous infusion over 20 mins

or (if on regular phenytoin)

  • Phenobarbital 20 mg/kg intravenously over 5 mins

Paraldehyde 0.8 ml/kg of mixture may be given after start of phenytoin infusion as directed by senior staff
Inform intensive care unit and/or senior anaesthetist


45 mins (5th step)

  • Rapid sequence induction of anaesthesia using thiopental sodium 4 mg/kg intravenously
  • Transfer to paediatric intensive care unit

Anticonvulsants
First line for long term control:


Sodium valproate is first line for the idiopathic childhood generalised epilepsy syndromes. Lamotrigine = 2nd line. Others = clobazam, topiramate, levetiracetam.

  • except for ABSENCE epilepsy (ethosuximide)
  • teratogenic (NTDs) during pregnancy; not for breastfeeding
  • 2x as likely to produce seizure freedom than other drugs
    - SEs include weight gain, hair loss. Deranged LFTs rarely

Carbamazepine is first line for focal epilepsies. Other options consider sodium valproate (but girls >9yo), lamotrigine - v effective but needs a slow titration, topiramate, levetiracetam.

  • SEs include dizziness, headache, nausea, sedation, dry mouth.
    Rash, neutropaenia, hyponatraemia, ataxia
  • not for pregnancy or breastfeeding
  • NOT for absence or myoclonic seizures as can make them worse

Age:


  • Neonatal seizures - rarely part of benign epilepsy syndrome, usually underlying severe cerebral dysfunction. Will not be generalised tonic clonic because brain not mature enough to synchronise


  • Infantile - challenging epilepsy, needs specialist. Includes differential of: benign myoclonic epilepsy of infancy (no further investigation/tx), West's syndrome = classical triad ofinfantile spasms - salaam attacks, hypsarrhythmia on EEG, developmental regression/delay, myoclonic epilepsy of infancy, myoclonic astatic epilepsy = likely to be unresponsive to AEDs, use of ketogenic diet

Breath-holding attacks: TODDLERS
think, old enough to get* angry /throw tantrum


Child cries, holds breath and goes blue. Brief LOC but full and rapid recovery.
Tx: behaviour modification therapy with distraction

Prolonged expiratory apnoea, usually no cardiac rhythm disturbance

Main anatomical exclusion that needs to be made = Budd-Chiari malformation (cerebellar tonsils sit low in the FM --> acute hydrocephalic episode)

Reflex asystolic seizures: infants and toddlers

  • suddenly going limp followed occasionally by clonic jerking.
  • precipitated by pain

Main differential = long QT syndrome
Must have an ECG to rule out long QT if first episode
Suspect if attacks come without warning

Investigation:


History - detailed witnessing of the episode.

  • specific triggers?
  • any impairments in child?

Examination - skin markers - neurocutaenous sydromes?

  • neurological abnromalities, focal signs?

EEG always important to do - identify abnormal background

  • unless seizure captured on EEG can only be supportive not diagnostic evidence
  • asymmetry or slow = ?structural abnormality?
  • hyperexcitability/sharp waves/spike-wave complexes
  • imaging (MRI and CT) not required routinely only if suspecting structural problem. Image if there are focal signs or focal seizures, signs between seizures
  • consider metabolic investigations if seizures coming with developmental regression or fits relating to feeding/fasting

Childhood absence epilepsy 4-12yos onset
stare momentarily, looks a bit like daydreaming, may twitch eyelid/hand
lasts a few seconds (not longer than 30s)
child has no recall
may realise they have missed something on regaining consciousness
only 2% of childhood epilepsy
Good prognosis - 95% remission in adolescence
Can be induced by hyperventilation
2/3rds are female

Lennox-Gastaut** 1-3 years old onset
Lots of different fits - DROP attacks**, tonic and atypical absences
Developmental arrest or regression
Behaviour disorder
Complex neuro problems in history often, infantile spasms, poor prognosis

WEST syndrome: 4-6 months onset, diagnosis by 1yr.
Flexor spasms of head trunk and limbs - extension of arms 'salaam attack'
last 1-2s, can happen in bursts, on waking
deterioration of social interaction
hypsarrhythmia on EEg
tx with vigabatrin or corticosteroids

Benign epilepsy with centrotemporal spikes:4-10 years old, onset in primary school
tonic clonic fits in sleep, or simple focal seizures
weird feelings in face and tongue
15% of all childhood epilepsies
doesn't require treatment often
focal sharp waves from Rolandic/centrotemporal area
remission in adolescence usually (majority)

Early-onset benign childhood occipital epilepsy (Panayiotopoulous): 1-14yrs old

  • visual disturbance, eye deviation vomiting, autonomic features in younger
  • headache and visual disturbance, distortion of images, hallucinations in older
    -remission in childhood
    Some may have learning difficulties

Juvenile myoclonic epilepsy: adolescence

  • mostly myoclonic but can other types
  • commonly after waking - 'throws drinks or cornflakes'
  • learning unimpaired
  • remission unlikely
  • requires lifelong tx but usually can be well managed
  • truly photosensitive
  • EEG characteristic with fragments and irregular discharges, polyspike

AED therapy can be discontinued after 2 years free of seizures (usually!)
Driving only after 1 year of seizure free for adolescents

SEs of AEDs:
Lamotrigine - rash
Ethosuximide (absence) - N+V
Topiramate (also for migraine) - drowsiness, withdrawal, weight LOSS
Gabapentin - insomnia
Levetiracetam - least SEs? Rarely sedation