paediatric seizures

see also:

• Mx of status epilepticus
• paediatric emergency medicine
• febrile convulsions
• anticonvulsants
• RCH clinical guidelines - Mx of afebrile seizures
• RCH clinical guidelines - Mx of febrile convulsions

• RCH patient information epilepsy
• RCH - seizures - safety issues and how to help (pdf)
• RCH - febrile convulsions (pdf)
• RCH - intranasal midazolam (pdf)
• RCH - buccal midazolam (pdf)
• RCH - seizures after acquired brain injury (pdf)

1. is it really a seizure? most are secondary to syncope and are not primary seizure disorders, even if there is incontinence or “post-ictal” confusional state
   • see is it really epilepsy?
2. what type of seizure disroder is it? See below
3. further Ix such as EEG, CT brain or MRI, consider home videos for difficult cases not witnessed by doctors
4. counselling - prognosis, activity risk management, ? Genetic counselling
5. anticonvulsant Rx - most probably as good as each other but need to assess adverse reaction profiles as this is what will generally limit success to only 50% for any one drug
6. drug levels have limited utility, mainly for compliance assessment, and then perhaps only for phenobarb and phenytoin. Valproate levels do not reflect CNS levels. Assessing levels may do more harm than good!
7. some may benefit from surgical Mx
8. home Rx with buccal midazolam 0.3mg/kg in 5mg/5ml has risk of resp. depression in up to 5% and takes 8 min to work on average, so only use if over 6 months old, has history of prolonged seizures lasting more than 10minutes, lives a distance from medical help, and parents are capable of using it appropriately.
9. 1-2% of those with severe poorly controlled seizures have sudden unexpected death (SUDEP) - mainly an issue in non-compliant adolescents

• genetic (60%) vs structural or symptomatic (40%)
• focal (60%) vs general (40%)

• JME - most common cause
• Dravet syndrome
• APNFLE
• CAE
• benign focal epilepsy of childhood
• etc

• genetic or developmental - eg. Tuberous sclerosis
• acquired
  • Hippocampal sclerosis
  • trauma
  • CNS infections
  • etc
• cryptogenic - 30-40% of all paed epilepsies

• epilepsy associated with 1st presentation, anticonvulsant withdrawal, intercurrent illness, esp. if fever.
• prolonged febrile convulsion
• CNS infection
• metabolic disturbance (eg. hypoglycaemia, hyponatraemia, or hypocalcaemia)
• trauma

• hypoxia
• drugs
• trauma
• infection - meningitis, TORCH
• hyperglycaemia
• hypoglycaemia
• pyridoxine deficiency - Rx pyridoxine 100mg
• biotinidase deficiency - typically hypotonic, pale with sparse hair. Rx oral biotin

• infection
• drug withdrawal - cocaine
• hypoglycaemia
• hypocalcaemia
• developmental malformation
• intracranial haemorrhage
• inborn error of metabolism
• hyponatraemia or hypernatraemia
• benign familial neonatal seizures - 15% will develop a seizure disorder

• infection
• hypocalcaemia - esp. if preterm, small for age, diabetic mother, or Hx asphyxia; DiGeorge syndrome;
• hyperphosphataemia
• hypomagnesaemia
• hyponatreamia
• developmental malformation
• drug withdrawal
• inborn error of metabolism

• febrile convulsion
• birth injury
• infection
• toxin
• trauma
• metabolic disorder
• cerebral degenerative disease

• febrile convulsion (until age 5yrs)
• idiopathic
• benign Rolandic - 3 to 13 yrs, >50% are nocturnal only, grow out of it, no Rx needed, often have tonic facial grimace resembling stroke
• infection
• trauma
• cerebral degenerative disease