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Seizures in Children
Seizures are a periodic disturbance of the brain’s electrical activity, resulting in some degree of temporary brain dysfunction.
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. 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 or become confused.
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 those in adults (see Seizure Disorders). However, some types of seizures, such as febrile seizures (see Febrile Seizures) and infantile spasms (see Infantile Spasms), occur only in children.
In newborns, seizures may be caused by temporary metabolic abnormalities or by a serious disorder, such as a brain malformation, injury of the brain during pregnancy, lack of oxygen during birth, a serious infection, or a hereditary disorder of metabolism. Newborns who have seizures are evaluated immediately to check for such serious causes. Seizures caused by hereditary disorders of metabolism typically start during infancy or childhood.
Certain conditions in children, such as breath-holding (see Breath-Holding Spells) and night terrors (see Sleep Problems in Children : Night Terrors and Sleepwalking), 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, they can interfere with the child's development. Whether some types of recurring seizures can affect the developing brain is debated.
Some Causes of Seizures in Newborns and Infants
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), magnetic resonance imaging (MRI), or sometimes ultrasonography to check for malformations of the brain, bleeding, tumors, and other structural damage to brain tissue (for example, by a stroke)
Treatment focuses mainly on the cause. Sometimes children need to take drugs to control seizures (anticonvulsants).
When a child has a convulsion, parents or other caregivers should do the following to try to protect the child from harm:
After the seizure ends, the following can help:
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 the seizure lasts more than 5 minutes, if the child is injured during the seizure or has difficulty breathing after the seizure, or if 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.
If seizures last 15 minutes or more (called status epilepticus), doctors give drugs such as the sedative lorazepam or the anticonvulsant fosphenytoin, usually by vein (intravenously), to end the seizures. If a drug cannot be given intravenously, diazepam gel may be applied to the rectum. Children with status epilepticus are carefully monitored for problems with breathing and blood pressure.
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 (see also Seizure Disorders : Treatment).
Sometimes changing the diet can help prevent seizures. For example, some doctors prescribe a ketogenic diet. This 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 a modified ketogenic diet, such as the Adkins diet (which is less strict), is used instead. 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.
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 also done when the dose is changed and sometimes 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.
If children continue to have seizures while taking two or more anticonvulsants or if side effects are intolerable, epilepsy surgery may be an option. 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 MRI, continuous video-EEG (in which brain waves and a video of the child are recorded at the same time), single-photon emission CT (SPECT—see Single-photon emission computed tomography (SPECT)), and positron emission tomography (PET—see Positron Emission Tomography (PET)). 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. Also, when the child senses that a seizure is starting or when a family member sees a seizure begin, a magnet 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.
In infantile spasms (salaam seizures), children suddenly raise and bend their arms, bend their neck and upper body forward, and straighten their legs.
Many children who have infantile spasms also develop abnormally or have intellectual disability.
Electroencephalography and analysis of samples of blood, urine, and the fluid around the spinal cord as well as brain imaging help doctors diagnose the disorder and identify the cause.
Injecting adrenocorticotropic hormone into a muscle or giving a corticosteroid or one type of anticonvulsant by mouth often helps control the spasms.
Infantile spasms last for only a few seconds but typically occur close together in a series that lasts several minutes. Children may have many series of spasms a day. Spasms usually start when children are younger than 1 year. They may stop by age 5 years, but often, another type of seizure then develops.
Usually, infantile spasms occur in infants who have a serious brain disorder or developmental problem, which may have already been diagnosed. These disorders include
Brain tumors may result from tuberous sclerosis, a hereditary disorder that is a relatively common cause of infantile spasms (see Tuberous Sclerosis). Sometimes no cause can be identified.
Spasms usually consist of a sudden jerk of the whole body. They typically occur soon after children wake up and rarely occur during sleep.
In most affected children, intellectual development, including development of language skills, is slow, and intellectual disability is present. When infantile spasms start, children may at least temporarily stop smiling or lose developmental skills that they have learned, such as being able to sit up or roll over.
Doctors base the diagnosis on symptoms and results of electroencephalography (EEG), which is done to check for specific patterns of abnormal electrical activity in the brain.
Magnetic resonance imaging (MRI) of the brain is done to look for signs of brain damage or malformations. Samples of blood, urine, and the fluid around the spinal cord (cerebrospinal fluid) are usually analyzed to check for disorders that may be causing the spasms. Cerebrospinal fluid is obtained by doing a spinal tap (lumbar puncture).
If the diagnosis is still unclear, genetic tests may be done.
Because early control of infantile spasms is associated with a better developmental outcome, early identification and treatment of spasms are essential. The most effective treatment is adrenocorticotropic hormone (ACTH), injected into a muscle once a day. A corticosteroid (such as prednisone), given by mouth, may also be effective.
The only other drug that has been clearly proved to help stop the spasms is the anticonvulsant vigabatrin. It is particularly helpful when tuberous sclerosis is the cause. There is insufficient evidence that any other anticonvulsant or a ketogenic diet is effective.
Sometimes epilepsy surgery is done to eliminate the cause of the spasms. An area of the brain may be surgically removed if seizures are caused by only that one area and that area can be removed without significantly affecting the child's ability to function.
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