This document discusses seizures in childhood. It begins with objectives of identifying key elements in evaluating individuals with seizures, recognizing features of febrile seizures, and distinguishing epileptic from non-epileptic seizures. It then covers definitions, classifications of seizures including infantile spasms and febrile convulsions, investigations such as EEG and imaging, management of status epilepticus, anti-seizure medications, and seizure-like disorders that can mimic epilepsy.

1. Seizures in
Childhood
Mohammed Abu Aish, MD,FRCPC,MEd
Credit and thanks to:
Dr. Mohammed O. Fattani

2. 1. Identify the key elements in the evaluation of an
individual with seizures.
2. recognize the key features of febrile seizures
3. Recognize the key differences between epileptic
and nonepileptic seizures.
Objectives

3. Introduction
 Definitions
 Classification
 Infantile spasm
 Febrile convulsions
 Status epilepticus
 Management
 Seizure like disorders

4. Introduction
 Incidence of convulsions 3.5%
 Is it a diagnosis?

5. Introduction:
Prevalence of epilepsy in developed countries
=0.5-1 %
 Males > females
High in low socioeconomic

6.  Introduction
 Definition
 Classification
 Infantile spasm
 Febrile convulsion
 Investigation
 Status epilepticus
 Management
 Seizure like disorders

7. Seizure:
 Paroxysmal involuntary disturbances
of brain function (loss of consciousness
, disturbance of motor. sensory
behavioral. autonomic dysfunction.
What is Epilepsy?

8. Epilepsy is defined as 2 or more unprovoked
afebrile seizures.
(International League Against Epilepsy).

9. What's about seizures occurring during acute
illness e.g. , meningitis or hypocalcaemia ?

10. History is the cornerstone of an accurate
diagnosis
HOW TO DIAGNOSE EPILEPSY

11. History
Chief complaint analysis/ Associated symptoms
Relevant systemic review
Relevant PM/PS/M/I/A/P/D/N/F/S

12. Chief complaint analysis/ Associated
symptoms
Detailed description of attack:
GENERALIZED VS FOCAL
FIRST TIME ?, KNOWN CASE OF ?
ONSET/ TIME OF THE DAY/ PROGRESSION
DURATION/ FREQUENCY
CHANGE IN TONE/ COLOR/ BLADDER AND BOWEL
CONTROL/ Tongue bite/ EYE POSITION/ DROOLING AND
FROTHING

13. Chief complaint analysis/ Associated
symptoms
DESCRIPTION OF POST ICTAL STATUS (Todd's
paralysis , postictal dysphasia
Precipitating factor such as fever , acute illness,
emotional or physical or trauma, INGESTIONS
Do the episodes always occur when the child is
upset and crying, during sleep

14. SYSTEMIC REVIEW
DETAILED CNS SYSTEMIC REVIEW
VISION
Headaches
IRRITABILITY/ LETHARGY
FEVER
RASH
Vomiting
SYMPTOMS OF INFECTIONS (URTI/GI/UTI)

15. RELEVANT PAST HX
Repeated seizure, use of AED, initial abnormal
EEG,
COMPLIANCE WITH MEDICATIONS/ RECENT
CHANGES/ RECENT WEIGHT CHANGE
Past previous history of meningitis,HIE, head
trauma / IMMUNIZATION
Family history (dominant inheritance )
consanguinity/ SOCIAL HX
Teenager with seizure( suspect drug abuse)

16. Etiology
Any insult to the cerebral cortex can cause seizure(
symptomatic) vs idiopathic / cryptogenic
In future the idiopathic is likely to be smaller group
shifting towards symptomatic group , because
(1) advanced neuroimaging (subtle malformation
dysplastic and migrational disorder
(2) advances in genetic research ( chromosomal
location , and abnormal gene product )

17.  Introduction
 Definition
 Classification
 Infantile spasm
 Febrile convulsion
 Investigation
 Status epilepticus
 Management
 Seizure like disorders
 Vedio

18. Different method of classification
Since 1981 till now
Partial
Generalized
Is still the broadest use .

19. Classification of seizures
 Why classification is very important
 Type → diagnosis
 Prognosis
 Select the treatment
 EEG pattern

20. Partial Seizures

21. 1) simple 2) complex
 Simple partial. s.
 Motor activity
 Preserved consciousness
 May have Aura “ headache etc.”
 No post ictal phenomenon
 EEG
 Prognosis excellence

22. 2) Complex
a) Complex partial seizures:
 Motor activity
 Impaired consciousness
 Aura
 Difficulty to diagnose in infant + small
children
 Automatism common
 Infant, alimentary e.g chewing
 2ndary generalization

23. Complex
b) Benign COMPLEX partial epilepsy (Rolandic)
 Common
 Excellent Progresses
 Age 9 – 10 years ( resolve before puberty)
 Normal Children – unremarkable past history
 Normal neurologically

24. b) Benign COMPLEX partial epilepsy (Rolandic)
 Family History
Mostly confined to the face ipsilateral limbs
e.g – numbness of the cheek
75% during sleep ( GTC)
Investigation:
EEG: diagnostic
Centrotemporal spikes (Rolandic)

25. Generalized Seizures

26. 1)Absence seizures: 
Sudden cessation (stoppage) of motor activity.
 Age of onset 5 years
 Never associated with Aura
 No postictal state
 No loss of body tone

27. 2) Generalized tonic – clonic seizure
 Very common
 Aura
 Eyes roll back
 Tonic → clonic movement
 Loss of sphincter control
 Bite tongue

28. What are the precipitating factors?
1. Fever
2. Fatigue
3. Emotional stress
4. Drug e.g theophylline

29.  Introduction
 Definition
 Classification
 Infantile spasm
 Febrile convulsion
 Investigation
 Status epilepticus
 Management
 Seizure like disorders
 Vedio

30. Infantile spasms:
onset: 4 –8 months
3 types: Flexor
Extensor
Mixed most common
What is the description of the attack
5 month → cry → sudden flexion – extension
of neck trunk – Extremities frequently →
fatigue
EEG. Characteristic Hypsarrythmia

31. Classification:
1 – Cryptogenic
2 – Symptomatic

32. Infantile spasm
1. Cryptogenic up to 20%
Normal birth history
Developmentally normal
CNS + MRI all normal
Good prognosis

33. 2. Symptomatic
Prenatal + perinatal factors
Hypoxic – ischeamic encephalopathy
Congenital infection
Inborn error of metabolism
Structural abnormalities of the brain
Postnatal
CNS infection
Trauma
Prognosis bad 90% → M.R

35.  Introduction
 Definition
 Classification
 Infantile spasm
 Febrile convulsion
 Investigation
 Status epilepticus
 Management
 Seizure like disorders
 Video

36. Febrile convulsion:
Introduction
Most common seizures
Excellent prognosis
Onset 5 month – 5 years.
Incidence 3%

37. Clinical manifestation (Typical FS)
 Generalized
 1 – 10 min (<15 min)
 One seizure in the febrile illness
 Child is back to normal after the post ictal stage

38. Clinical manifestation (Typical FS)
 Fever ( usually caused by URTI, OM)
 Controlling the fever does not reduce the risk of seizure
 EEG not indicated routinely
 risk of Epilepsy 1%(same as general poulation)

39. When EEG indicated?
Atypical F.C
 Duration > 15 min
 Repeated fit in the same day
 Focal seizure
At risk of Epilepsy 5-7%

40. Who are the patient with FC at risk of Epilepsy ?
 +ve Family history of Epilepsy
 Initial fit started < 9 month:
 Atypical seizure
 Delayed milestone
 CNS abnormality

41. When shall we consider lumbar puncture ?

42. Lumbar puncture should be considered strongly in
infants younger than 12 months
those who have prolonged focal febrile seizures
children who are partially treated with antibiotics
Any age with signs of meningitis

43. 3 % incidence of having a single feb.conv
30 % of them get recurrence of febrile convulsion
30 % got family history of FC
30 % of focal FC present as status epilep.
Role of figure 3 in Febrile convulsion

44. Febrile Convulsion
Treat the cause of the infection
↓ Temp., Drug, Sponging
Reassurance
Prophylaxis not indicated
Oral Diazepam 1 mg/kg/day divided 3 doses for 2 – 3
days. (old), Clobazam (new)

45.  Introduction
 Definition
 Classification
 Infantile spasm
 Febrile convulsion
 Investigation
 Status epilepticus
 Management
 Seizure like disorders
 Video

46. What shall we do for the first Afebrile
seizures?
Only simple investigation
Limited role of blood work (? Ca, Glu, Lytes,
Gas)
Afebrile Seizures

47. Investigation of seizures:
Selection of investigation depends on
 Age
 Type
 Neurological finding

48. EEG: Abnormal in 60%(interictal)
Abnormal in 99%(ictal)
Precipitating factors
• Hyperventilation
• Eye closure
• Photic stimulation
• Sleep deprivation
CT Scan. MRI: should be reserved for selected
cases with suspected lesion

49. Indication for CT or MRI:
1 – Complex partial seizures
2 – Focal neurological signs
3 – ↑ Frequency; or severity
4 – Changing seizures pattern
5 – ↑ I.C.P

50.  Introduction
 Definition
 Classification
 Infantile spasm
 Febrile convulsion
 Investigation
 Management
 Status epilepticus
 Seizure like disorders
 Video

51. Treatment of Epilepsy
1. Is it a convulsion?

52. Treatment of Epilepsy
Is it 1st attack??

53. Treatment of Epilepsy
Is it 1st attack?? 70% does not recur

54. Treatment of Epilepsy
3. What is the goal of therapy??

55. 5. What other blood tests indicated during
drug therapy.
• CBC 1st 3 months
• LFT

56. What are the indications of blood
monitoring of the anticonvulsant?

57. When to do Drug level?
1. At onset
2. Non compliance
3. At status epilepticus
4. Patient on poly therapy
5. Uncontrolled seizure
6. For? Drug toxicity
7. Hepatic or renal failure

58. When to stop the Drug?
How to stop the drug?

59. When to stop the Drug? 2 years
How to stop the drug ? = 3 months

60. Anticonvulsant Drug.
1. Bendozodiazepines:
a. Diazepam
IV :Status Ep.
b. Lorazepam
c. Clonazepam
Oral: myoclonic. Ep.
d. Nitrazepam

61. 2. Carbamazepine: “Tegretol”
Partial
Generalized
Dose (10 – 30 mg/k/day BD)
Follow up monitoring
CBC + Diff (Leucopenia)
LFT.
.

62. 3. Ethusuximide:
Absence. EP

63. Phenobarbitone “luminal”
Generalized EP
 Status EP
Dose: loading 20 mg/kg. IV
maintenance 3 –5
Side Effect:
 Behavioral Changes
 Cognitive + learning disabilities

64. Valproic Acid “Depakene”
 Generalized EP
 Myoclonic
 Absence
focal
Dose 30 – 60 mg/k/day BD TID
 Side Effect:
 GIT
 Alopecia
 Hyperphagia
Very rare
 Hepatotoxicity < 2 years
 Reye’s syndrome

65. ACTH:
 Drug of choice for infantile spasm 6 weeks
 Followed by prednisilone 6 weeks

66. 4. Gabapentin ( SABRIL)
 Add on Drug
 Refractory complex partial
5. Lamotrigine:
 Add on Drug
 Complex partial
 Generalized tonic – clonic Seizures
 Lenonx – Gastaut syndrome

67. Topamax (Topiramate)
Add on Drug
 spectrum anticonvulsant medication

68. Keppra
Partial
Generalized
20-60 mg/kg in two divided dose

69. Is there any place for surgery?
Focal
EEG
CT and MRI

70.  Introduction
 Definition
 Classification
 Infantile spasm
 Febrile convulsion
 Investigation
 Management
 Status epilepticus
 Seizure like disorders
 Video

71. Status epilepticus
Definition: Seizure > 30 min
Serial convulsion with no return of
consciousness

72. Common Causes
1. Febrile seizure (focal)
2. Sudden withdrawal
of anticonvulsant/ non compliance
3. Symptomatic: eg. Structural anomalies
- encephalitis. Etc
- metabolic causes

73. Treatment of status epilepticus
ABCDE
Call for help/ put the patient in the resuscitation
room/ apply universal precautions.
Airway:
– secure and open airway, O2, position/ jaw thrust /
no foreign bodies
Breathing:
– Air entry/ RR/ distress/ O2/ Sat monitor

74. ABCDE
Circulation:
– check pulses/ HR/ BP
– Establish 2 large bore IV lines ( consider IO if no IV
could be obtained after 2 attempts)
– Investigations to send (CBC, electrolytes, Drug
level, ABG,
– Check Blood sugar and correct if hypoglycemic
– If dehydrated or shocky ( 20 ml/kg NS bolus)

75.  Disability ( Examine head for trauma, pupils,
consciousness level, focal CNS signs
 Exposure ( remove clothes. Temp ( antipyretics if febrile)
/ signs of trauma or bleeding
ABCDE

76. SPECIFIC TREATMENT:
First line Drugs:
Diazepam; 0.1 – 0.3 mg/kg/dose (+ 3 dose)
Lorazepam: 0.05 – 0.1 mg/kg. Less ↓ BP ↓
Respiratory arrest
Midazolam 0.2 – 0.3 mg/kg IM ( better than rectal
diazepam)

77. 2nd Line Drugs
Phenytoin IV 20 mg/k/dose ( + N.S) 20min.
OR
Phenobarbitone 20 mg/k/dose 10 min.

78. If no Response ↓
3rd line drugs:
Keppra IV 30 mg/kg
Other options( rectal paraldhyde/ IV Valproic acid)

79. If no Response ↓
Barbiturate coma (ventilate) ICU + EEG
↓
General anesthesia (halothane)

80.  Introduction
 Definition
 Classification
 Infantile spasm
 Febrile convulsion
 Investigation
 Management
 Status epilepticus
 Seizure like disorders
 Video

81. Differential diagnosis of pseudo
seizures
 Arrhythmia
 Benign myoclonus of sleep
 Breath-holding spells
 Dystonic reaction
 Hyperekplexia
 Jitteriness
 Migrainous syndromes
 (confusional, basilar)
 Opsoclonus-myoclonus-
ataxia syndrome
(neuroblastoma)
 Paroxysmal movement
disorders
 Psychiatric disorders
 (attention-deficit
hyperactivity disorder,
hysteria, rage attacks)
 Psychogenic nonepileptic
seizures (pseudoseizures)
 Sandifer syndrome
 Self-gratification disorder
 Shuddering attacks
 Sleep disorders (pavor
nocturnus/night terrors,
somnambulism/sleepwalkin
g, narcolepsy)
 Spasmus nutans
 Syncope
 Tics, stereotypies

82. 1 ) MIGRAINE
if presented with acute neurological events with out significant
headache , particularly those with loss or alteration of
consciousness. ( basilar-type migraine)
post-traumatic migraine : neurological signs occurring after minor
head trauma ( cerebral concussion).
 MIGRAINE = headache first
SEIZURES = headache later

83. 2 ) BENIGN PAROXYSMAL VERTIGO BPV
 4 years old child manifested by recurrent episodes
of brief disequilibrium , vertigo or dizziness . the child
will grasp nearby persons or furniture for support , last <
1 minute with out loss of consciousness . it recur in
clusters daily for several days then remitting for several
weeks. It is a diagnosis of exclusion. (atonic seizure)
 Prognosis is good with out treatment.

84. 3 ) NONEPILEPTIC STARING SPELLS
((PSEUDOABSENCES OR DAY DREAMING))
 It occur in children with mental retardation , ADHD,
autism and in normal children.
 Made up one-third of those referred for EEG.
 must be differentiated from true absence seizures as it
occurred if bored, inactive or in classroom.
 Interrupted easily and never associated with automatism
or other motor movement.
 hyperventilation might be +ve.

85.  4 ) PSYCHOGENIC NONEPILEPTIC SEIZURES
 Abnormal behavior or motor events in a conscious individual
misdiagnosed as epilepsy treated with antiepileptic drugs.
 typically in teenagers (11-14 YEARS ) with affective and anxiety
disorder.
 high risk in those with a family or a friend history of seizures.


86. 5 ) SYNCOPE
 Abrupt loss of consciousness , usually because of a sudden
reduction of a cerebral perfusion.
 Mostly are vasovagal in origin.
 Distinguished from seizures by the situation in which they
occur. ( emotional, standing, pain )
 Pallor with visual changes, and lack of postictal state .

87. 6 ) LONG Q-T SYNDROM
 rare life threatening cardiac condition.
 present without provocation , mimicking seizures with loss of
consciousness and pallor but lacking postictal state.
((usually find cardiac examination/or ECG
abnormalities))

88. 7 ) BREATH HOLDING SPELLS
 Toddlers.
 A benign disorder, should be preceded by stimulus then
consistent crying followed by pallor or cyanosis, abnormal
movement ends with regaining level of consciousness.
 It never occur without crying, always grow out of it .

89. 8 ) MOVEMENT DISORDERS ( TICS, TREMORS, CHOREA DYSTONIA ,
ATHETOSIS , HEAD BANGING ,k)
 Classical motor activity.
 Sustained rather than episodic .
 No loss of consciousness.
 They may coexist with seizures.
RELIEF BY SIMPLE TOUCHING .( GESTE ANTAGONIST )

90. 9) SLEEP DISORDERS ( SLEEP WALKING , NIGHT TERRORS ,
CONFUTIONAL AROUSAL )
 It is common for an individual or a family to manifest more than
one of these disturbances.
 Sleep walking up to 15% of children, around 6 years, eyes
open, low level of awareness, slow, clumsy ,purposeless.
(( should be differentiated from postictal wandering of night
seizures ))

91. 10 ) SLEEP STARTS ( HYPNIC MYOCLONUS )
A sudden jerking movement upon falling asleep
accompanied by sensation of falling , occurring
at any age and are restricted to sleep usually in
the transitional period between sleep and
wakefulness.