Categories: NeurologyPaediatrics

Seizures and Epilepsy in Children

What is a seizure?

  • Our brain cells communicate with each other via electrochemical signals.
  • A seizure is caused due to an abnormal burst of electrical activity in the brain.
  • It may lead to jerking movements of the body, change in behaviour and loss of consciousness.

What is epilepsy?

  • A child is said to have epilepsy when there are two or more unprovoked seizures more than 24 hours apart.
  • The term ‘unprovoked seizure’ means a seizure not triggered by an infection, metabolic disturbance or toxin ingestion.

People with epilepsy tend to have recurrent seizures or fits. Having one seizure doesn’t mean a child has epilepsy.

What is a ‘fit’ and a ‘convulsion’?

  • These terms are used interchangeably with ‘seizure’, and even ‘epilepsy’.
  • Involuntary movements such as ‘shaking’ or ‘jitteriness’ are called fits or convulsions or seizures.
  • It is important to note that all involuntary movements are not epileptic seizures and all epileptic seizures may not have involuntary movements (convulsion/fit).
  • The seizure may start in one part of the brain (focal seizure) or the whole brain at the same time (generalized seizure).
  • A focal seizure may spread to involve the whole brain (secondary generalization).

Why do children have epilepsy?

There are several causes of epilepsy. These are some of the most common causes:

  • New-born brain injury – lack of oxygen, infection, prematurity
  • Infection – meningoencephalitis, neurocysticercosis
  • Genetic conditions with/without brain malformations;
  • Head injury
  • Metabolic and genetic disorders
  • Stroke

In many cases, the cause of a seizure can’t be found. This type of seizure is called ‘Idiopathic’ or ‘cryptogenic’.

What does a seizure look like?

Every seizure does not have jerking movements of the arms and legs. Your child may have different type of symptoms depending upon the type of seizure.

  • Staring, unresponsive when called
  • Periods of rapid eye blinking and staring – looks like ‘daydreaming’
  • Jerking movements of the arms and legs
  • Tightening (stiffening) of the body
  • Sudden fall to the floor or to one side without any obvious reason
  • Nodding of the head or head dropping down
  • Sudden jerking of the arms or legs – like a ‘startle’
  • In an older child – sudden jerking of the arms leading to dropping the toothbrush, spoon
  • Loss of bowel or bladder control
  • Appearing confused or in a haze

During the seizure, your child’s lips may become blue and breathing may not be normal.

The symptoms of a seizure may resemble other problems or medical conditions. Always consult your child’s doctor to confirm the diagnosis.

After a seizure

  • After a seizure, the child will slowly regain consciousness.
  • He/she may seem drowsy or confused, and will not be able to recall the event.
  • Several children complain of a headache or body ache after a seizure. Some children may be tired or irritable for the rest of the day.

Common Types of Seizures

A. Generalised tonic-clonic seizure (GTC)

  • The child suddenly stops his/her activity, is unresponsive when called.
  • Sometimes, there is uprolling of eyeballs or staring to any one side.
  • This may be accompanied by a cry or fast breathing.
  • There may be drooling and twitching of the mouth.
  • The muscles of the body, face tighten up and then contract and relax in quick succession which causes jerky, rhythmic movements.
  • After some time, the muscles relax and the child goes limp and eyes close. The end of This signal of the seizure.

A GTC seizure may be associated with

  • Passage of urine and/or stools
  • Tongue bite

B. Absence seizure

  • In an absence seizure, the child suddenly stops what he/she was doing and stares into space as though they are daydreaming. There is no response or reaction when called. This may last from 5 to 15 seconds. The child has no memory of the event.
  • Absence seizure may occur several times in a day.
  • Many times, these events are brought to notice by the school teacher who has complained that the child is daydreaming and not paying attention in class.

C. Infantile spasms

  • These seizures are typically seen in the first year of life. The child seems to ‘startle’ ie. Sudden upward movement of the arms and legs drawn up towards the abdomen. These episodes may occur in clusters – 2-5 times at a time and may be accompanied by crying.
  • Many times, spasms may be mistaken for colic or constipation in the infant.
  • A child with spasms has a regression or delay in neurodevelopment.

D. Focal seizure

  • This seizure type involves one part of the body. There may be spread to the other side (secondary generalisation). The child may be aware of what is going on (intact awareness) or is unconscious (without intact awareness).
  • Sometimes, focal seizures are preceded by an ‘aura’. An older child may mention feeling fear, crampy feeling in the stomach, odd taste or smell, or just a feeling of the seizure ‘coming on.

E. Febrile seizures

https://kidhealthindia.org/febrile-seizures/

How is epilepsy diagnosed?

A diagnosis of epilepsy involves a comprehensive assessment of your child’s medical history, details about the seizure/s and a neurological exam.

Your child’s Neurologist will suggest tests to look for causes for the seizure – for instance,  

  • A blood test to rule out low blood sugar levels, electrolytes to rule out metabolic causes, tests to rule out infection.
  • A Video electroencephalogram (EEG) is a way of measuring the electrical activity in the brain and is usually carried out to identify the type of epilepsy.

The child may also need a brain scan (MRI/CT scan) to detect whether a structural brain abnormality (blood vessel abnormality, brain tumour, and stroke) may be the cause.

Getting an MRI can be a scary process for a child.

  • At NH SRCC, our expert team of Pediatric Anaesthetists and Radiologists make sure that the child is calm and comfortable during the procedure.
  • We have a separate room (tunnel room), where the child is first acclimatized with help of toys, pictures, headphones to block noise and then shifted for the scan once ready.

During an MRI exam, your child may be given a contrast agent (dye) through an intravenous line (IV). A contrast agent can sometimes help us provide an accurate diagnosis of certain conditions.

Spinal Tap (lumbar puncture)

  • It is done to rule out an infection or a metabolic disorder to be the cause of the seizure.
  • In this test, a thin needle is inserted in between two vertebral bones in the lower back to obtain cerebrospinal fluid for testing.
  • Though invasive, it is a relatively safe and simple test.

Genetic testing

  • May be advised to determine the cause for epilepsy.

Epilepsy and Management

 Why is seizure control important?

  • 80% of the brain grows in the first 4 years of life
  • Uncontrolled seizures during this ‘crucial period’ interfere with normal brain development.
  • Recurrent seizures are associated with
  • Cognitive decline
  • Behavioural and psychiatric problems, poor quality of life
  • Increased risk of injury (fall, drowning) and
  • Sudden unexpected death in epilepsy (SUDEP)

The goal of epilepsy management is to

  • stop seizures to enable the child’s normal growth and neurodevelopment
  • with as few treatment-related side effects as possible

Medications

  • Several anti-seizure medications are now available.
  • Strictly speaking, they are not a cure for seizures but are used to prevent seizures.
  • Your child’s doctor will decide the right anti-seizure medication for your child
  • It is important to prescribe the correct medication that will be most effective for your child’s seizures and have the least side effects.
  • Once started, anti-seizure medications need to be taken regularly and at a fixed time.

How long does my child have to take anti-seizure medications? 

  • The duration of medication will be decided by your physician.
  • Generally, these medications need to be taken for a minimum of two years. Occasionally, they may need to be taken for several more years.
  • Do talk to your child’s doctor if you are concerned about medication side effects or any other worries.
  • Do not stop the medication without discussing it with your doctor.

Other treatment options:

  • The ketogenic diet (KD)
  • Vagus Nerve Stimulation (VNS Therapy®)
  • Epilepsy Surgery

 What precipitates a seizure? 

There are certain triggers for having a seizure, even while your child is on anti-seizure medication.

  • Sleep deprivation- not sleeping well, not getting enough sleep
  • Fatigue, emotional stress
  • During an illness
  • Flashing bright lights (playing video games in the dark)
  • Alcohol or drug use
  • Associated with the menstrual cycle or other hormonal changes

Seizure First–Aid

  • If a child experiences a tonic-clonic seizure – the most important thing is to stay calm! Donor panic!
  • Gently place your child on the floor.
  • Turn the child on his/her side to prevent choking.
  • Do not try to hold the child’s hands or legs or put anything in the child’s mouth – no finger, spoon – you may risk hurting yourself or breaking the child’s teeth
  • Do not make the child smell a shoe or onion – it will not stop the seizure
  • Try to keep track of how long the seizure lasts.
  • In case the seizure lasts more than 3 minutes – use Midazolam Nasal Spray as directed by your child’s doctor.
  • If the seizure has lasted longer than ten minutes get the child to the nearest hospital at once.

What happens next?

  • The vast majority of children with epilepsy can lead full and active lives.
  • A large number of children with epilepsy will be controlled on medication and the seizures will stop gradually.
  • The chances of this happening will depend on the type of epilepsy a child has.
  • They can go attend regular school and have a normal schedule.
  • There are no restrictions on food, except if your child is following the Ketogenic diet.
  • They can attend most sports activities – talk to your doctor before starting a new activity.

Can my child continue to swim?

  • In some situations, losing consciousness or physical control due to a seizure could be harmful.
  • However, imposing strict restrictions on a child’s daily activities can be challenging and be detrimental to normal emotional and physical development.
  • Your doctor will discuss the likelihood of a future seizure and risk for injury.

Certain precautions to be taken, including but not limited to:

  • Water (pool, lake, sea): A child with seizures should be closely supervised by an adult who can immediately come to the child’s rescue (1:1 watch)
  • Avoid heights (climbing trees, playground equipment, building terrace)
  • Riding a bicycle – helmet is necessary. Avoid cycling on roads with a lot of traffic. Supervision is advisable.
  • Children that have frequent seizures, particularly atonic or drop attacks, will sometimes need to be fitted with a helmet to prevent head injury.

Your child’s doctor will advise you if there are any precautions that the child should take, and whether any activities need to be avoided.

Dr. Anaita Hegde | Senior Consultant – Neurology – Paediatric and  Dr. Puja Mehta | Associate Consultant – Neurology – Paediatric |  SRCC Children’s Hospital, Mumbai

Narayana Health

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