Pediatrics

1. EPILEPSY IN CHILDREN

2. WHAT IS EPILEPSY?
 Epilepsy is a chronic neurological condition
characterized by recurrent, unprovoked
seizures, occurrence of at least 2 unprovoked
seizures 24 hours apart.
 Epileptic seizure → clinical manifestation of
abnormal & excessive discharge of a set of neurons
in the brain

3. CAUSES
 Idiopathic (70 – 80%) – cause unknown but presumed
genetic
 Secondary
 Cerebral dysgenesis /malformation
 Cerebral vascular occlusion
 Cerebral damage
- Antenatal: Congenital infections, drugs, alcohol
- Natal: HIE, birth trauma
- Postnatal: IVH in prematurity, CNS infections,
kernicterus, trauma, tumour
 Cerebral tumours
 Neurodegenerative disorders
 Neurocutaneous syndrome

4. Seizures: Pathophysiology:
Sustained partial depolarisation in a group of
neurons -->excitability --> sudden
depolarisation in response to stimuli --
>conduction to surrounding cells, distant
synaptically connected cells & subcortical
neurons -->dissemination -->loss of
consciousness

6. OLD CLASSIFICATION

7. GENERALISED SEIZURES:-
(Discharge arises from both hemisphere)
Absence seizures
Myoclonic seizure
Tonic
Tonic clonic
Atonic seizures
FOCAL – SEIZURES ARISE FROM ONE OR
PART OF ONE HEMISPHERE
Frontal seizures
Temporal lobe seizures
Occipital seizures
Parietal lobe seizures
ILAE 2010 CLASSIFICATION

8. Seizure classification

9. CLASSIFICATION

10. PARTIAL SEIZURES ---FOCAL SEIZURES

11. Focal seizure-affect part of the brain
 Aware:
Alert, involuntary movement, odd taste/smell,
fear/happiness, sweating/goose bumps
 Impaired awareness:
Aura, unconscious, lip smacking, meaningless
movements, picking at clothing, wandering
around, repeating words

13. SPECIAL EPILEPSY SYNDROME
1.INFANTILE SPASM:-
-Most cases appears in 1st yr of life.
- Single brief recurrent gross flexion movements of
the limb …rarely extension movements
-EEG shows multifocal,multiple small spikes.
-On maturity it disappears(4 to 5yr)
-CT & MRI mostly normal.
-Later progress to LENOX GASTAUT SYND.

14. HISTORY TAKING
HOPI:-
 Two unprovoked seizures >24 hr apart suggest the presence of an
epileptic disorder
 Any aura?change in the behaviour?
 Types of seizures
-tonic clonic(tensing,then shaking,LOC)
-atonic(drop attack)
-absence(jus staring,not responding,blinking)
-partial(maybe consciouss,only ½ limbs shaking/jerking
 How long did it last?frequency?time of day?precipatating factor?
 Any loss of consciousness?tongue bitting?
 What did you do for the child?(appropriate first aid measures)
 Post ictal:drowsy?sleeping?vomiting?

15. PHYSICAL EXAMINATION
•Consciouss level
•Posture
•Deformity
•movement
•Dysmorphism,head size and shape
•Cranial nerves
•Gait
•Spine
•Neurocutaneous signs
1. café-au-lait spots
2. Neurofibromata
3. adenoma sebaceum

16. Diagnosing Epilepsy
 Detailed history and physical examination
 EEG, video EEG
 Imaging ( CT, MRI, PET)

17.  The clinical diagnosis is more important then any tool…
(H/O, Eye witnesses, substantiated by video if available)
 # EEG:-
 EEG is most sensitive tool for diagnosis which shows
electrical activity changes in the brain but it also require
clinical correlation
 Many children with epilepsy may have normal EEG and
many children who will never have epilepsy have EEG
abnormalities
 Done for dx, classification, selection of anti-epileptic drugs
and prognosis
DIAGNOSIS

18. MANAGEMENT AND TREATMENT

19. Management of Seizures
 Initial assessment
Airway
Breathing
Circulation
 Call for help
Hospitalist
Neuro
PICU/RRT
 Ask for more history
 How long has the
patient been seizing?
 New-onset vs. known
seizure disorder
 Baseline seizure
frequency, is this
typical or not?
 Events leading up to
this episode
 Meds/triggers
 History of status

20. Management of Seizures
 Consider rapid work-up for underlying
etiologies
CNS infection
Acute HIE
Metabolic disease
Electrolyte imbalance
TBI
Drugs, intoxications, poisonings
Cerebrovascular event

21. Seizures - Management
 I Management of acute attack:
 Calm down
 Head down lateral position
 Prevent hurt
 If does'nt stop convulsing in 3-5 min,
 Inj Diazepam 0.3 mg/kg slow iv bolus
 Maybe repeated after 20 min
 Effect lasts 0.5-3 hrs
 SE- hypotension, respiratory depression,
secretions
or
 Rectal diazepam 0.5 mg/kg dose/ nasal midzolam 0.2
mg/kg/dose

22. PRINCIPLES OF ANTICONVULSANT THERAPY
 Treatment recommended if ≥ 2 episodes→ recurrence
risk 80%
 Attempt to classify the seizure type & epileptic syndrome
 Monotherapy as far as possible → most appropriate drug
→ increase dose gradually till epilepsy controlled,
maximum dose reached / side effects occur
 Alternative monotherapy (Add on the 2nd drug if 1st drug
failed. Optimise 2 nd drug, then try to withdraw 1st drug.
 Rational combination therapy (usually 2 or maximum 3
drugs )
Combines drugs with different mechanism of action &
consider their spectrum of efficacy, drug interactions &
adverse affects

23.  Monitor drug levels (carbamazepine, phenytoin,
phenobarbitone) to check compliance → if seizures not
well controlled/in situations of polypharmacy where drug
interaction is suspected.
 When withdrawal of medication is planned → seizure
free for 2 years, consideration should be given to
epilepsy syndrome, likely prognosis & individual
circumstances before attempting slow withdrawal of
medication over 3-6 months (longer if clonazepam/
phenobarbitone)
 If seizures recur → last dose reduction is reversed &
medical advice sought

24. PARTIAL SEIZURES
Simple partial
Complex partial
Sec.generalised
FIRST LINE
carbamazepine
valproate
SECOND LINE
lamotrigine
topiramate
levetiracetam
phenytoin
Phenobarbitame
clonazepam
GENERALISED
SEIZURES
tonic clonic
Clonic
Absence
Atpical absence
Atonic,clonic
Myoclonic
Infantile spasms
valproate
valproate
valproate
Valproate,clonazepam
ACTH,prednisolone
lamotrigine
topiramate
levetiracetam
phenytoin
Phenobarbitame
Clonazepam
Lamotrigine
Topiramate,clonazepam
Topiramate,phenobarbitone,
piracetam,levetiracetam,lam
otrigine.
Nitrazepam,valproate

25. First line AEDs
Carbamazepine:
 Ind: Partial, tonic clonic
 Dose: 10-30 mg/kg/d in 2-3 doses13-18 hrs,
 Adv: Relatively safe, improves cognitive fn.
 SE: Diplopia,drowsiness, giddiness
initially.Hepatitis, skin rash, BM depression, drug
interactions, dystonia, can aggravate minor motor
seizures

26. First line AEDs
Sodium valproate:
Ind: Broad spectrum
Dose: 20-30 mg/kg/d (upto 80) in 2-3 doses
Half Life; 7-10 hrs
SE: Nausea, vomiting, wt gain, hair loss,
hepatic failure, tremors, platelets, s
ammonia, s carnitine, no correlation
between drug levels & toxicity, levels of
other AEDs

27. First line AEDs
Phenobarbitone
Ind: Tonic-clonic, partial, febrile
Dose: 3-6 mg/kg/d as single doses
level:10-15 g/ml20-80 hrs
Adv: Cheap, once daily dose
SE: Drowsiness, hyperkinesia, cognitive
impairment ??, rash, rickets

28. First line AEDs
Diphenylhydantoin:
Ind: Tonic-clonic, atonic, partia
Dose: l4-8 mg/kg/d in 2 doses
level: 10-20 g/ml
Half Life: Upto 20 hrs
SE: Hirsutism, gum hyperplasia, rickets,
ataxia, lymphoma like syndrome, Sle like
illness, megaloblastic anemia, rash, low
margin of safety

29. Ethosuximide:
Ind: Absence seizures
Dose: 20-25 mg/kg/d in 2 doses
Half Life: 4-30 hrs
SE: Photophobia, WBC, nephrosis, blood
dyscrasia
ACTH:
Ind: West syndrome
Dose: 20-40 u/d for 4-6 wks
SE: hypercortisolism

30. Nitrazepam
Ind: Myoclonus, atypical absence
Dose: 0.5 mg/kg/d in 2 doses
SE: Sleepiness, salivation,hypotonia, ataxia,
tolerance
Clonazepam
Dose: 0.05-0.25 mg/kg/d in 3 doses
 Drug level monitoring
 EEGs
 When to stop ? 2-3 yrs seizure free

31. Newer AEDs
Clobazam
Ind: Partial, generalised & myoclonus (add on drug)
Dose: 0.5 mg/kg/d single dose
SE: Drowsiness, tolerance,  secretions
Gabapentin
Ind: Secondarily generalised, complex partial
SE: liver enzymes, impaired swallowing & aspiration,
somnolence, fatigue, dizziness, wt gain
Lamotrigine
Ind: Generalised, absence, JME, LG syndrome
SE: Synergy with valproate, skin rash, SJ syndrome

32. Newer AEDs/ Other modalities
Topiramate:
Ind: Partial, generalised, drop attacks, LG syndrome
SE: ?cognitive impairment
Vigabatrine:
Ind: Partial, infantile spasms
Dose: 40-80 mg/kg/d
SE: Drowsiness, agitation, confusion
Oxcarbazepine:
Derivative of carbamazepine
 Ketogenic diet
 Surgery

33. Seizures: Status epilepticus:
 Prolonged seizure for >20 min or repeated
seizures without regaining consciousness
 Persistent seizure activity  hypoxia,
hypoglycemia, hyperthermia, cerebral
edema & vasomotor instability
 Life threatening
 Risk of permanent brain damage 
Medical emergency

34. Mx of Status epilepticus
ICU, monitoring
IV dextrose drip
Oxygen
IV Inj Diazepam 0.3 mg/kg or Lorazepam 0.1 mg/kg (longer action)
or Midzolam (lesser respiratory depression)
Inj phenytoin 15-20 mg/kg iv at a rate of <1mk/kg/min
Inj Phenobarbitone 20 mg/kg iv at a rate of 1 mg/kg/min or
IV Valproate 20 mg/kg as infusion in 50 ml NS over 30 min
Ventilatory support + diazepam/midzolam infusion
`` Thiopental infusion

35. INTRACTABLE EPILEPSY?
 Re- evaluate the following possibilities
 Is it a seizure /non epileptic event
 Anticonvulsant dose not optimized
 Poor compliance to anticonvulsant
 Wrong classification of epilepsy syndrome → wrong
anticonvulsant
 Anticonvulsant aggravating seizures
 Lesional epilepsy, hence a potential epilepsy surgery
candidate
 Progressive epilepsy or neurodegenerative disorder

36. Non-medication therapies
 Vagus Nerve Stimulator (VNS)-prevents
seizures by sending regular, mild pulses of
electrical energy to the brain via the vagus
nerve
 Deep Brain Stimulation (DBS)-electrodes placed
in target areas in the brain provide brain
stimulation to help stop the spread of seizures
 Ketogenic Diet- 3-4 gms of fat for every 1 gm
carb and protein

37. Seizure Triggers
 Missed dose of medication
 Sleep deprivation
 Illness
 Stress, anxiety, overstimulation
 Hormonal changes
 Alcohol and drugs of abuse
 Hyperventilation
 Flashing lights
 Temperature extremes
 dehydration

38. Seizure Remission
 The International League Against Epilepsy
(ILAE) has proposed to expand the
definition of remission to 10 years seizure-
free with the last 5 years off antiepileptic
drugs (AEDs).

39. ADVICE FOR PATIENTS
 Educate and counsel on epilepsy.
 Emphasize compliance if on anticonvulsant.
 Don’t stop the medication by themselves.this may
precipitate breakthrough seizures.
 In photosensitive seizures-watch tv in brightly lit
room.avoid sleep deprivation.
 Use a shower with bathroom door unlocked
 No cycling in traffic,climbing sports or swimming
alone.
 Know emergency treatment for seizure
 Inform teachers and school abt the condition.

40. Caleb is a 3 month old male who presents to your clinic with his
parents. They state over the past couple of weeks Caleb has been
having “weird movements”. Upon further questioning they report
that the movements consist of flexion of his trunk and extension of
his extremities in clusters particularly upon early morning
wakening.
A: Reassure them that babies sometimes have strange
movements
B: Refer them immediately to neurology for workup
including an EEG and to consider ACTH or high dose
steroids
C: Start them on Keppra and give them Diastat for
emergencies
Case Study 1

41. Brady is a 7 yo male who was brought into your clinic for evaluation
of inattention. His parents state he will often stop and stare for
about 30 seconds as if he is day dreaming. It occurs multiple times
a day and his teacher is reporting he is not listening in class and
his grades are dropping.
A: put him on Adderall for ADHD
B: tell him they need to discipline him better
C: Refer him to neurology for an EEG and to consider
treatment with Ethosuximide
Case Study 2

42. Thank You!!