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Seizures in Children

By Margaret C. McBride, MD, Professor of Pediatrics (Neurology);Director, Neurodevelopmental Center, Northeastern Ohio Universities Colleges of Medicine and Pharmacology, Rootstown;Akron Children’s Hospital ; M. Cristina Victorio, MD, Assistant Professor in Pediatrics;Director, Headache Program; Pediatric Neurologist, Northeast Ohio Medical University;Akron Children's Hospital

Seizures are a periodic disturbance of the brain’s electrical activity, resulting in some degree of temporary brain dysfunction.

  • When older infants or young children have seizures, they often have typical symptoms, such as shaking or jerking of part or all of the body, but newborns may only smack their lips, chew involuntarily, or periodically go limp.

  • Electroencephalography is used to diagnose the disorder, and blood and urine tests, brain imaging, and sometimes a spinal tap are done to try to identify the cause.

  • When a child has a convulsion, parents or other caregivers should try to protect the child from harm—for example, by keeping the child away from stairs, sharp objects, and other potential hazards.

  • Treatment focuses mainly on the cause, but if seizures continue after the cause is treated, children are given anticonvulsants.

Seizures are an abnormal, unregulated electrical discharge of nerve cells in the brain or part of the brain. This abnormal discharge can alter awareness or cause abnormal sensations, involuntary movements, or convulsions. Convulsions are violent, involuntary, rhythmic contractions of the muscles that affect a large part of the body.

Epilepsy is not a specific disorder but refers to a tendency to have recurring seizures that may or may not have an identifiable cause.

Seizures in children are often similar to seizures in adults. However, some types of seizures, such as febrile seizures and infantile spasms, occur only in children.

Certain conditions in children, such as breath-holding spells and night terrors, may resemble seizures but do not involve abnormal electrical activity in the brain and thus are not seizures.

A seizure itself does not appear to damage the brain or cause lasting problems unless it continues for more than about an hour (most seizures last only a few minutes). However, many disorders that cause seizures can cause lasting problems. For example, some disorders can interfere with the child's development. Whether some types of recurring seizures can affect the developing brain is debated.

Causes of Seizures

In newborns, seizures may be caused by

  • Temporary metabolic abnormalities, such as a low blood sugar level

  • A serious disorder, such as a brain malformation, injury of the brain during pregnancy, lack of oxygen during birth, or a serious infection

  • Inherited disorders that result from mutations in a gene such as hereditary disorder of metabolism

  • Use of certain drugs by the mother during pregnancy

Seizures caused by hereditary disorders of metabolism typically start during infancy or childhood.

Some Causes of Seizures in Newborns and Infants

Type

Disorder

General disorders

High fevers

Infection in the blood (sepsis)

Lack of oxygen, as may occur during labor or delivery

Brain disorders

Bleeding (hemorrhage) within the brain

Brain malformations

Infections, such as encephalitis or meningitis

Tumors (rarely)

Metabolic disorders

Hereditary disorders that affect the processing (metabolism) of amino acids, fats, or carbohydrates

Temporary abnormalities in blood levels of sugar (glucose), calcium, magnesium, vitamin B6, or sodium

Drugs

Use of drugs (such as cocaine, heroin, or the sedative diazepam) by the mother during pregnancy, resulting in withdrawal in the infant

Symptoms

In newborns, seizures may be difficult to recognize. Newborns may smack their lips or chew involuntarily. Their eyes may appear to gaze in different directions. They may periodically go limp.

In older infants or young children, one part or all of the body may shake, jerk, or tighten up. The limbs may move without purpose. Children may stare, become confused, have unusual sensations (such as numbness or tingling) in parts of the body, or have unusual feelings (such as feeling very afraid for no reason).

Did You Know...

  • Sometimes seizures cause children to simply stare or appear confused instead of causing convulsions.

Diagnosis

  • Electroencephalography

  • Other tests to check for a cause

Newborns who have seizures are evaluated immediately to check for serious causes and causes that can be corrected.

If a child has had a seizure, doctors do a physical examination. They also ask the parents whether any family members have had seizures.

Electroencephalography (EEG—a test that records brain waves using sensors placed on the scalp) is done to check for abnormal electrical activity in the brain. EEG is done while infants or children are awake and asleep.

Doctors do other tests to check for a cause. These tests may include

  • Measurement of the oxygen level in the blood using a sensor clipped on a finger (pulse oximetry) to determine whether the oxygen level is low

  • Blood tests to measure blood sugar (glucose), calcium, magnesium, sodium, and other substances to check for metabolic disorders

  • A spinal tap (lumbar puncture) to obtain a sample of the fluid around the brain and spinal cord (cerebrospinal fluid), which is analyzed and checked for brain infections and other disorders

  • Cultures of blood and urine to check for infections

  • Brain imaging tests, such as computed tomography (CT) or magnetic resonance imaging (MRI), to check for malformations of the brain, bleeding, tumors, and other structural damage to brain tissue (for example, by a stroke)

Treatment

  • Immediate measures to prevent injury

  • Treatment of the cause

  • Anticonvulsants

Treatment of seizures in infants and children focuses mainly on the cause of the seizure. Sometimes children need to take drugs to control seizures (anticonvulsants).

Immediate measures to prevent injury

When a child has a convulsion, parents or other caregivers should do the following to try to protect the child from harm:

  • Lay the child down on one side

  • Keep the child away from potential hazards (such as stairs or sharp objects)

  • Not put anything in the child’s mouth and not try to hold the child’s tongue

Did You Know...

  • Contrary to popular opinion, people should not put anything in the mouth of someone who is having a seizure.

After the seizure ends, the following are important:

  • Staying with the child until the child is fully awake

  • Checking whether the child is breathing and, if breathing is not apparent, starting mouth-to-mouth rescue breathing (if the child is having convulsions, attempting rescue breathing is unnecessary and can injure the child or the rescuer)

  • Not giving any food, liquid, or drug by mouth until the child is fully awake

  • Checking for fever and, if present, treating it

Fever can be lowered by giving the child acetaminophen by suppository placed in the rectum if the child is unconscious or too young to take drugs by mouth or by giving acetaminophen or ibuprofen by mouth if the child is conscious. Also, warm clothing should be removed.

An ambulance should be called if any of the following occur:

  • The seizure lasts more than 5 minutes.

  • The child is injured during the seizure or has difficulty breathing after the seizure.

  • Another seizure occurs immediately.

All children should be taken to the hospital the first time they have a seizure. For children who are already known to have a seizure disorder, parents should discuss in advance with the doctor when, where, and how urgently evaluation is required if another seizure occurs.

Seizures that last 15 minutes or more (called status epilepticus) are a medical emergency. Doctors give drugs, such as the sedative lorazepam or the anticonvulsants fosphenytoin or levetiracetam by vein (intravenously), to end the seizures. If a drug cannot be given intravenously, diazepam gel may be applied to the rectum, or midazolam liquid may be given into the nose (intranasally). Diazepam and midazolam are sedatives that can help stop seizures. Children with status epilepticus are carefully monitored for problems with breathing and blood pressure.

If newborns continue to have seizures after the cause is treated, they are given anticonvulsants intravenously. These newborns are then closely observed to check for possible side effects, such as slowed breathing.

If anticonvulsants control the seizures, they may be stopped before newborns are discharged from the nursery. Whether anticonvulsants are stopped depends on the cause of the seizures, their severity, and the results of the EEG.

Long-term treatment

Long-term treatment may involve

  • Anticonvulsants

  • A ketogenic diet

  • Surgery

If children have only one seizure, they usually do not need to take an anticonvulsant (see Table: Using Drugs to Treat Seizures in Children). Anticonvulsants are used if seizures recur or are likely to recur.

The anticonvulsant dose is usually increased if a standard dose does not adequately control seizures. The dose may also be adjusted as children grow and their weight increases. Another anticonvulsant may be added or substituted if the first one was only partly effective or had bothersome side effects. Anticonvulsants can interact with other drugs, so parents should tell their child's doctor all the drugs and supplements the child is taking.

When some anticonvulsants are used, doctors do blood tests to measure the level of the drug, which helps determine whether the dose is correct. These tests are sometimes repeated when the dose is changed or when a new drug is started.

The need to continue taking anticonvulsants depends on what caused the seizures and how long children have been seizure-free. Most children continue taking anticonvulsants until they have had no seizures for 2 years. The risk of having a seizure after 2 seizure-free years is less than 50%. However, having another disorder that affects the brain and nerves (such as cerebral palsy) increases the risk of having another seizure.

When anticonvulsants are to be stopped, the dose is reduced over a period of time rather than stopping the drug all at once.

A ketogenic diet may be prescribed in some situations. This restrictive diet is very low in carbohydrates and very high in fat. When the body breaks down fat to use for energy, substances called ketones are formed. In some children, the ketones help control seizures. The ketogenic diet must be carefully followed and requires that the amounts of foods be measured precisely. Even one bite or taste of a restricted food can lead to a seizure. Children may have difficulty following such a strict diet. A doctor and a dietician must supervise use of the diet. Sometimes the Atkins diet is used instead. It is a less strict form of the ketogenic diet. If children who are following a ketogenic diet improve substantially, the diet is often continued for at least 2 years. Side effects of a ketogenic diet may include a low blood sugar level, sluggishness (lethargy), and weight loss.

Epilepsy surgery may be an option if children continue to have seizures while taking two or more anticonvulsants or if side effects are intolerable. This operation involves surgically removing an area of the brain. It is usually done only when seizures are caused by only one area in the brain and that one area can be removed without significantly affecting the child's ability to function. Sometimes this operation substantially reduces the number of seizures a child has. Tests may be done to help locate the area in the brain that is causing seizures. These tests include the following:

  • MRI to determine the functions of the areas of the brain near the area that is causing the seizures (called functional MRI)

  • Continuous video-EEG (in which brain waves and a video of the child are recorded at the same time)

Before surgery is done, a neurosurgeon and a neurologist explain the risks and benefits of surgery to the parents. Even when surgery reduces the frequency and severity of seizures, many children need to continue to take anticonvulsants. However, they can usually take lower doses or fewer drugs.

Stimulating the vagus nerve can sometimes reduce the number of seizures children have. This procedure can be used in children as young as 4 years old. Doctors consider using this procedure when anticonvulsants are ineffective and epilepsy surgery is not possible. To stimulate the vagus nerve, doctors implant a device that resembles a heart pacemaker under the left collarbone and connect it to the vagus nerve in the neck with a wire that runs under the skin. The device causes a small bulge under the skin. The operation is done on an outpatient basis and takes about 1 to 2 hours. The device turns on and off all the time and thus periodically stimulates the vagus nerve. The doctor can easily and painlessly change the settings for stimulating the nerve using a magnetic wand placed over the device. Also, when the child senses that a seizure is starting or when a family member sees a seizure begin, a magnet (often worn in a bracelet) can be used to set the device to stimulate the nerve more often.

Vagus nerve stimulation is used in addition to anticonvulsants. Possible side effects include hoarseness, cough, and deepening of the voice when the nerve is stimulated. Vagus nerve stimulation usually makes the child more alert. Increased alertness may improve attention but sometimes interferes with sleep.

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Drugs Mentioned In This Article

  • Generic Name
    Select Brand Names
  • TYLENOL
  • ADVIL, MOTRIN IB
  • VALIUM
  • KEPPRA
  • No US brand name
  • ATIVAN
  • CEREBYX

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