This document discusses seizures in children, including febrile seizures. It defines seizures and different types, like generalized seizures and focal seizures. It covers the epidemiology, causes, clinical presentation and diagnosis of seizures. Complications, both acute and chronic, are outlined. Investigations and management approaches are also summarized. The document focuses in particular on febrile seizures, their definition, causes, types, evaluation and treatment in children presenting with fever and seizures.

1. Seizures in Children
Definition, Epidemiology, Etiology,
Clinical Presentation, Complications,
Investigations, Management
Prof. Imran Iqbal
Fellowship in Pediatric Neurology (Australia)
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

2. (God Almighty speaking to Prophet Muhammad (PBUH)
The Rahman (The All-Merciful Allah) has taught the Qur‘an.
He has created man. He has taught him (how) to express himself.
The Holy Quran; surah Al-Rahman 55:1-4
In the name of Our Creator Allah, the most Gracious, the most Merciful

3. CNS

4. Brain

5. Our perceptions and Movements

6. Clinical Presentation
of
CNS diseases

7. CNS disease – Clinical Presentation
• Seizures / Convulsions / Fits
• Impaired Conscious level
• Developmental delay
• Intellectual handicap
• Neurological Paralysis / Paresis (motor weakness )
• Neuromuscular disorders / Hypotonia
• Movement disorders
• Headache
• Regression of acquired milestones
• Behaviour problems

8. Seizures in Children
Definition, Epidemiology, Etiology,
Clinical Presentation, Complications,
Investigations, Management

9. Seizures / Convulsions / Epilepsy
Definition, Clinical Presentation, Etiology

10. Seizures in Children
Definition
• Seizure is a paroxysmal involuntary disturbance of brain
function that may manifest as impaired conscious level,
abnormal motor activity, behavioral abnormalities, sensory
disturbances or autonomic dysfunction
• Convulsion is a generalized seizure with increased tone and
tonic - clonic movements of the body
• Epilepsy is a disorder of the brain characterized by an
enduring predisposition to generate seizures
• Epilepsy is recurrent seizures unrelated to fever or an acute
cerebral insult

11. Seizures in Children (Clinical Presentation)

12. Convulsions

13. Seizures in Children
Epidemiology, Etiology

14. Seizures in Children
Epidemiology
• Febrile seizures are the most common seizure disorder and
most common neurological disorder in childhood
• Febrile seizures are seen in 3 % of children aged 6 months
to 5 years (rarely, 3 months and 6 years)
• Epilepsy is predisposition to recurrent seizures
• Epilepsy is seen in 5 per 1000 children

15. Seizures in Children
Etiology - Acute Symptomatic Seizures
• Febrile Seizuress (age 6 months to 5 years)
• CNS infections (Meningitis / Encephalitis / Cerebral malaria)
• Intracranial hemorrhage
• Hypoglycemia / Electrolyte imbalance (Na,Ca,Mg)
• Drugs / Chemical Poisoning / Encephalopathy
• Trauma
• Hypoxia
• PNES (Psychological Non-epileptic Seizures)
• Tetanus (spasms not seizures)

16. Seizures in Children
Etiology - Recurrent Seizures
• Epilepsy
 Idiopathic Epilepsy in children has a genetic basis
 Epilepsy in children may be secondary to:
 Hypoxic-ischemic injury to Brain
 Cerebral Malformations
 Degenerative Brain diseases
 Epilepsy in children may be associated with:
Cerebral palsy
Intellectual disability / Mental handicap

17. Seizures in Children
Clinical Presentation

18. Seizures in Children
Clinical Diagnosis
• Description of Seizures
• Video evaluation
• Detect and Look for important signs of seizure activity:
• Impaired conscious level
• Tonic spasms, clonic jerky movements
• Froth at mouth, facial movements
• Passage of urine or stool
• Post-ictal sleep

19. Seizures in Children
Generalized Motor seizure (GTCS)

20. Seizures in Children
Focal Motor Seizure

21. Seizures in Children
Differential Diagnosis
• Breath – Holding Spells
• PNES (Psychological Non-epileptic Seizures, Pseudoseizures)
• Parasomnias (sleep disorders)
• Syncope
• Tics
• Movement disorders
• Gratification disorder

22. Seizures in Children
Psychological (Pseudo) Seizure

23. Seizures in Children
Evaluation
• History:
• Seizures – Onset, Frequency, Duration, Progression
• Seizure – Description, Video evaluation, Type
• Present illness – other symptoms of disease
• Past History – seizures
• Development history – milestones
• Family History – epilepsy
• Physical Examination:
• General Physical Examination – all systems of body
• Neurological Examination – abnormal findings

24. Seizures in Children
Investigations
• CBC, CRP, ICT malaria, X-ray Chest (infection)
• Serum glucose, electrolytes, calcium, and BUN (metabolic)
• CSF examination and microbiology (meningitis)
• Neuroimaging - CT / MRI Brain (neurological disease)
• EEG – electroencephalography (epilepsy)

25. Seizures in Children
ILAE Classification
International League Against Epilepsy

26. Seizures in Children
ILAE Classification – 1981
• Partial Seizures (part of body affected)
- Simple Partial Seizures (consciousness retained)
- Complex Partial Seizures (consciousness lost)
• Generalized Seizures (all of the body affected)
- Generalized Tonic-clonic Seizures (grand mal epilepsy)
- Myoclonic Seizures
- Absence Seizures (petit mal epilepsy)
• Unclassifiable seizures

27. Seizures in Children
Focal vs Generalized Seizure
Focal Onset Seizure Generalized Onset Seizure

28. Seizures in Children
ILAE Classification – 2017
• Focal (Onset) Seizures:
- Motor
--- Aware
--- Impaired Awareness
- Non-motor
• Generalized (Onset) Seizures:
- Motor
--- tonic-clonic
--- myoclonic
- Non-motor (Absence)
• Unknown Onset Seizures:

29. Seizures in Children
ILAE Classification – 2017

30. Seizures in Children
Complications

31. Seizures in Children
Acute Complications
• Hypoxia and Hypercapnia
• Hypoglycemia
• Hyperpyrexia
• Aspiration pneumonia
• Shock
• Raised ICP (Intracranial Pressure)
• Physical injuries
• Status epilepticus

32. Seizures in Children
Delayed Complications
• Epilepsy (Recurrence of Seizures)
• Neuronal damage
• Hypoxic-Ischemic Brain Injury
• Cerebral Palsy
• Mental handicap / Intellectual disability
• Behavior problems

33. Seizures in Children
Management

34. Seizures in Children
Acute Management
• General Management:
• Airway – Breathing – Circulation
• Oxygen by mask / nasal prongs
• Monitoring – GCS, Vitals, SaO2,
• Seizure Management:
• Rectal diazepam (at home)
• IV diazepam or IV midazolam (benzodiazepines)
• IV Leviteracetam (if needed)

35. Febrile Seizures
Definition, Epidemiology, Etiology,
Clinical Presentation, Complications,
Investigations, Management

36. Febrile Seizures
Definition
• A Febrile seizure is a seizure occurring in a child having fever
(100.4°F or greater) without central nervous system
infection or any disease predisposing to seizures
• Febrile seizures are likely to recur with next episode of fever
in 30 – 50 % of children
• Risk of developing Epilepsy in children with Febrile seizures
is 3 % in uncomplicated cases

37. Febrile Seizures
Epidemiology
• Febrile seizures are the most common seizure disorder and
most common neurological disorder in childhood
• Febrile seizures are seen in children aged 6 months to 5
years (rarely, 3 months and 6 years)
• Febrile seizures are seen in 3 % of children

38. Febrile Seizures
Etiology
• The exact underlying mechanism of febrile seizures is
unknown
• The increased activity of neurons during rapid brain
development may predispose to seizures in younger
children
• Inflammatory mediators, and cytokines, released during a
fever may contribute to the pathogenesis of febrile seizures
• There is a genetic basis to febrile seizures which are more
common in families

39. Febrile Seizures
Case Scenario
• An 18 months old child presents to the pediatric emergency
with sudden onset of jerky tonic-clonic movements of body
which lasted five minutes.
• Parents say the child was having runny nose and cough since
yesterday
• On examination, his weight is 10 kg and he has a
temperature of 102 F. Now he has no seizure activity but is
lethargic
• Mother mentions that the child did not have any such event
before.
• What will be your most likely initial diagnosis in this child ?

40. Febrile Seizures
Clinical Features - Fever
• Febrile seizures are associated with an abrupt rise of fever in
genetically-predisposed children
• Fever is usually more than 102 F (39 C)
• Most febrile seizures will occur during the first 24 hours of
developing a fever
• In many children, parents may not have noticed the fever till
the seizure occurs
• The cause of fever is usually a viral infection

41. Febrile Seizures
Clinical Features - Seizure
• Febrile Seizures are usually brief, lasting less than 5 minutes
• Most commonly, it is a generalized tonic-clonic seizure.
• Child rapidly loses consciousness with open deviated eyes,
irregular breathing, increased secretions, and pallor
• Bilateral jerky movements occur
• Child may vomit or become incontinent
• After the seizure is over, child rapidly regains consciousness,
within an hour

42. Febrile Seizures
Types
• Simple Febrile Seizures (80 %) - low risk of epilepsy (2–3 %)
• Complex Febrile Seizures (20 %) – increased risk (5 – 10 %)

43. Febrile Seizures
Evaluation
• History:
• Present illness – symptoms and signs
• Past History – seizures
• Development history – milestones
• Family History – epilepsy
• Physical Examination:
• General Physical Examination – cause of fever
• Neurological Examination – abnormal findings, SOMI

44. Febrile Seizures
Differential Diagnosis
• CNS infections (Meningitis / Encephalitis )
• Intracranial hemorrhage
• Hypoglycemia / Electrolyte imbalance (Na,Ca,Mg)
• Drugs / Poisoning / Metabolic Encephalopathy
• Idiopathic Epilepsy

45. Febrile Seizures
Diagnosis
• Febrile Seizures – fever often high
• Febrile Seizures – infectious cause of fever usually present
• Febrile Seizures – past history of Febrile seizures often
present in the child or siblings
• Febrile Seizures – child is neurologically normal before the
seizure
• Febrile Seizures – child regains consciousness quickly
• Febrile Seizures – child is neurologically normal after the
seizure
• Febrile Seizures – no other disease explains for the seizure

46. Febrile Seizures
Complications
• Acute complications:
• Hypoxia
• Hypoglycemia
• Hyperpyrexia
• Aspiration pneumonia
• Status epilepticus
• Chronic complications:
• Recurrence – further Febrile Seizures
• Epilepsy

47. Febrile Seizures
Investigations
• Typical case of Febrile seizures – investigations not needed
• Atypical cases or uncertain diagnosis – investigate as needed
(keeping in view other diseases)
• CBC, CRP, ICT malaria, X-ray Chest (infection)
• CSF examination and microbiology (meningitis)
• Serum glucose, electrolytes, calcium, and BUN (metabolic)
• Neuroimaging - CT / MRI Brain (neurological disease)
• EEG – electroencephalography (epilepsy)

48. Febrile Seizures
Acute Management
• General Management:
• Airway – Breathing – Circulation
• Oxygen by mask / nasal prongs
• Monitoring – GCS, Vitals, SaO2,
• Seizure Management:
• Rectal diazepam at home
• IV diazepam or IV midazolam (benzodiazepines)
• IV Leviteracetam (if needed)
• Fever Management:
• IV Paracetamol
• Sponging with water

49. Febrile Seizures
Long Term Management
• Control of Fever :
• Oral Paracetamol or Oral Ibuprofen (keep fever low)
• Sponging with water
• Seizure Management at home:
• Rectal diazepam
• Oral Midazolam
• Prevention of Seizures:
• Oral diazepam during febrile episodes
• Oral Phenobarbitone daily till 5 years of age

50. Status Epilepticus
Definition, Clinical Presentation,
Complications, Management

51. Status Epilepticus
• Status Epilepticus is defined as continuous or recurrent
seizure activity without regaining of consciousness lasting
for more than 5 minutes
• Status Epilepticus can lead to neurological damage in brain
• Multiple Complications can rapidly develop
• Control of Seizures is a Medical Emergency
• Management needs to be quick and comprehensive

52. Status Epilepticus
Acute Complications
• Raised Intracranial Pressure
• Hypoxia
• Hypercapnia
• Hypoglycemia
• Hyperpyrexia
• Shock
• Aspiration pneumonia
• Physical injuries

53. Status Epilepticus
Delayed Complications
• Hypoxic-Ischemic Brain Injury
• Cerebral Palsy
• Mental handicap / Intellectual disability
• Epilepsy
• Behavior problems

54. Status Epilepticus
Initial Management
• Airway – Breathing – Circulation
• Oxygen by mask / nasal prongs
• Monitoring – GCS, Vitals, SaO2,
• IV dextrose if Hypoglycemia
• Control of seizures

55. Status Epilepticus
Control of Seizures
• Initial Treatment:
• IV diazepam or IV midazolam (benzodiazepines)
• repeat diazepam or midazolam dose
• Seizures not controlled:
• IV Leviteracetam dose by infusion
• IV Phenytoin dose by infusion
• IV Phenobarbitone dose by infusion
• IV Sodium Valproate dose by infusion
• Seizures not controlled:
• IV Midazolam continuous infusion

56. Prof Imran Iqbal
Fellowship Pediatric Neurology-1991
Royal Children Hospital, Melbourne, Australia