Approach to Seizures in Children

Approach to Seizures
1. Seizure or Syncope (+others)
2. Provoked vs unprovoked? (Febrile?)
3. Focal or generalized?
4. What type of seizure?
5. Idiopathic vs symptomatic (secondary cause)?

1. Seizure vs Syncope vs Paroxysms

Seizure: a sudden disturbance of neurological function caused by an abnormal or excessive
sychronos neuronal discharge
Epilepsy: ≥2 unprovoked epileptic seizures

Syncope
Syncope Seizure
Trigger Common (upright, bathroom, unpleasant Rare (flashing lights, hyperventilation)
sight, sound, smell or pain, micturition, Often occurs spontaneously
cough, large meal)
Prodrome Almost always (presyncope) Common (aura)
Others: chest pain, palpitation, dyspnoea, E.g. unusual smell, rising sensation in
light-headedness abdomen, déjà vu

Onset Gradual (often minutes) Usually sudden

Duration 1-30 seconds 1-3 minutes
Convulsive jerks Brief Prolonged (>30 seconds)
Coarse & rhythmic
Incontinence Uncommon Common
Lateral tongue bite Very rare Common
Colour Very pale Pale (simple partial seizure)
Red/Blue (tonic-clonic seizure)
Post-ictal Rare (e.g. wakes up on floor) Common (e.g. wakes up in ambulance)
confusion > 5 mins (within 1h)
Recovery Rapid (quickly orientated) Slow (confused)
Other supporting Pallor during LOC Amnesia of events before and after
features Known CVS disease Headache and aching muscles after episode
Abnormal ECG

Causes of Syncope

Cardiac Non-Cardiac

Arrhythmias Structural Reflex Orthostatic Others

Long QT Cardiomyopathy HypoV

Vasovagal Toxins
Brugada Hypertrophic Drugs
Situational Heat stroke
WPW Dilated Addison’s
Breath-holding spells Anaphylaxis
Heart block Arrhythmogenic RV Others: pregnancy, anemia, anorexia
SVT Aortic stenosis
VT Coarctation
Pulmonary HTN
Myocarditis
Coronary artery disease
Approach to Seizures in Children

Non-epileptic paroxysmal disorders (“funny turns”)

- Paroxysm:
 Clear start and end etc cough, yawn

1. Breath Holding Attacks

- 1-2 years of age
- Types
 Cyanotic: Occurs when toddlers are upset  crying  stuck in a cycle of exhalation 
breathes out and holdsfall over
 Pallid: when startled or in pain  pale, sweaty, impaired responsiveness lasting minutes
- +/- jerking/stiffening
- Rapidly recover consciousness thereafter but may have post episode drowsiness due to the
hypoxia

2. Reflex Anoxic Seizures

- Triggersexcessive vagal responsevagal inhibtion of heartcardiac asystole
- Commonly triggered by pain, discomfort, minor head trauma, cold food, fear, fever
- Features
 Child becomes pale, cyanotic  stops breathing and falls to the floor
 May involve stiffening of body, limbs
 Episode is brief and child rapidly recovers
 Cerebral hypoxia may induce a GTC

3. Shuddering Spell
- Features
 5-15s
 Sudden neck flexion and arm adduction
 Trunk shivering “chill”, +/- stiffening
 Consciousness usually maintained
 Do not occur in sleep (unlike epilepsy)

4. Hypnic jerks aka hypnagogic jerks

- Spasmodic non-consistent jerks of the limbs
- Seen while falling asleep
- Split-second

5. Parasomnias e.g. Night terrors

6. Sandifer syndrome
- Severe GERD + spastic torticollis +/- hiatal hernia

7. Stereotyped movements

8. Conversion disorder: older children >5yo

9. Staring spells

- Staring spells: also seen in absence seizures, focal impaired awareness seizures
- DDx by history
 How often? While doing homework? Can relieve with calling
Approach to Seizures in Children

Others
1. Migraine
2. BPPV
3. Rigors
4. Myoclonic jerk
5. Movement Disorders
6. Acute life-threatening episode
Approach to Seizures in Children

2. Provoked vs Unprovoked?
- Rule out underlying cause provoking the seizure
- IF provoked – febrile vs afebrile?

Note: trigger ≠ provocations

- Most people would have a seizure given sufficient provocation, whereas triggers do not
usually cause seizures unless in epilepsy
- Provoked 1st seizures are less likely to recur (3-10%)

Provoked Seizures

Febrile Afebrile

Simple Complex Focal Generalized

6 months to 6 years Rule out V: Malformations, Stroke/BleedMetabolic

< 15 minutes Meningitis Head trauma Hypoglycaemia
Generalized seizure Encephalitis I: meningitis, encephalitis HypoNa
No focal neuro deficits N: Tumour Hypo/hypercalcemia
No developmental delay Hypo Mg
1 in 24 hrs Toxins
Drugs
Cardiac

3. If unprovoked – Focal vs Generalized?

Differentiating Generalized & Focal Seizures
*key in differentiating generalized vs focal is consciousness; not symmetry of symptoms or signs
2 components to consciousness:
- Arousal
- Response to external stimuli

Symmetrical Signs LOC Seizure Type

Yes Yes Generalized
No Yes Generalized
No Impaired consciousness (but Complex partial seizure
not fully lost)
No No Simple partial seizure
Yes No Not a seizure

Generalised Focal
Involves both hemispheres Involves 1 hemisphere
LOC? Always LOC - No LOC: simple
- Impaired consciousness: complex
Aura? No warning Can have aura reflecting origin site
Symmetr Symmetrical Asymmetrical, symptoms according to site
y - Frontal: Motor  stiffening (tonic), jerking
(clonic) of a limb
Approach to Seizures in Children

- Temporal: Auditory/ Sensory 

pain/numbness in a limb, smell/ taste
- Parietal: contralateral dysesthesia
- Occipital: Visualtransient homonymous
hemianopia
EEG Bilateral synchronous discharge/ varying
asymmetry
Simple - - Focal aware seizures (simple)
 Eye deviation to one side, asymmetric
limb involvement
 Focal motor, sensory, autonomic or
psych symptoms
 No post-ictal symptoms, awareness
unimpaired
Complex - Tonic  stiffening - Focal impaired awareness seizures
- Clonic  repeated, regular rhythmic (complex)
jerking  Pre-seizure: +/- aura
- Myoclonic: repeated, non-rhythmic  Seizure: impaired awareness but not
movements complete LOC
 Short, split sec (so can appear
 Slower to respond, inappropriate
awake)
response to stimuli
 EEG: burst of spike waves
 Focal motor, sensory, autonomic or
- Tonic-clonic
 Pre-seizure: psych symptoms
 Seizure:  Post-seizure
 S-min  Most commonly arise from
 Tonic then clonic temporal lobe, in which case
 Tonic: stiffen, might fall, not associated with post-ictal confusion
breathe cyanosis - Secondary generalised seizure (focal
 Clonic: jerk, irregular progress to generalised)
breathing, +/- tongue biting
and incontinence - +/- automatisms (meaningless complicated
 Post-seizure: hrs of LOC/ sleep actions)  e.g. plucking at clothes
- Absence
 4-8 yo, peak 6-7
 Pre-seizure:
 Triggered by running around,
laughing, hyperventilation
 Seizure:
 Sudden onset and termination
 Staring w/ brief LOC (<1min,
~10s)
 Eyelid fluttering, lip-smacking,
chewing movements
 Multiple episodes
 Post-seizure: behavior arrest
 EEG: 3Hz generalised spike-waves
and slow wave discharges
 Mx: ethosuximide, Na valproate,
lamotrigine
 (if given CBZ will go into status
epilepticus)
- Atonic  fall over, crumple up to
ground
Approach to Seizures in Children

Absence Focal impaired awareness

Duration Sec-1min Minutes
Freq 10s-uncountable Several per day-week
Behaviou Arrest Perseveration/ automatism
r
Trigger Hyperventilation
EEG Generalised 3Hz spike waves Focal ictal EEG
Mx ETX, VAL, LTG CBZ, LEV

4. Is this idiopathic or symptomatic (secondary)?

Epilepsy ≥2 recurrent unprovoked seizures, consisting of transient signs and/or symptoms

associated with abnormal, excessive or synchronous neuronal activity in the brain

Causes of Epileptic Seizure (> 1 week from disorder)

- Idiopathic (majority)
 Due to genetic predisposition to channelopathies leading to abnormal discharges in the
brain
- V:
 Cortical scarring
 Hippocampal sclerosis
 Vascular malformations Clues to a secondary cause:
 Stroke - History of developmental delay,
- I: SLE, sarcoidosis behavioural issues
- N: Space occupying lesion - Micro/macrocephaly
- C: - Neurocutaneous signs
 Developmental - Focal neuro deficits
 Tuberous sclerosis

History
Etiological Clues
Cause Clue
Provoked HypoNa - Tubulopathies: failure to thrive
- SIADH: pneumonia day 3
Tumor - Usually posterior fossa:
 Cerebellar signs e.g. abnormal gait
 Developmental regression
 Personality changes
Unprovoke Tuberous Fits, zits, nitwits
d sclerosis - Infantile spasms, focal seizures
- Shagreen patch, ashleaf macules
- Intellectual disability, ASD

Presenting Complaint
- Pre-seizure
 Onset
 Aura?
 Unusual smells, flashing lights, fear, rising sensation in abdomen
 DDX Syncope: light-headedness
 Syncope:
Approach to Seizures in Children

 Cardio: exertion, chest pain, palpitations

 Neuro: cough/ micturition, prolonged standing, crowed
 Postural: sitting to standing
 Triggers/precipitants
 Fever
 Flashing lights
 Crying, pain, cold, fear etc.
 Lack of sleep
 Head trauma
- Seizure
 What did it look like?
 Fainting, dropping to the floor
 Stiffening of body, limbs
 Shaking/jerking of limbs
 Unilateral vs bilateral (ask patient to point to the side of the seizure)
 Rolling of eyes
 Urinary incontinence
 Tongue biting
 Cyanosis? Pallor?
 Duration
 Is there loss of consciousness? (generalized vs focal)
- Post-seizure
 Head trauma?
 Confusion
 Recovery time

Red Flags
- Headache, neck stiffness, inconsolable crying, drowsiness, purpuric rash, photophobia
- Vomiting
- Weakness, numbness, BOV
- Head trauma
- Chest pain, cyanosis, SOB, palpitations, exertional syncope
- Ingestion of toxins or drug abuse

Systemic Review
- Fever
- Cough, cold, SOB
- Frequency, urgency, dysuria
- Vomiting, diarrhoea
- Rashes
- LOW, LOA, malaise
- AEIOU
Common Triggers in Epilepsy
Breakthrough seizure - Stress
- AED compliance - Lack of sleep
- Under-dosage? - Fever
- Any drug interaction? - Certain sounds
- Metabolic disorder? - Flickering lights/TV
- Underlying structural lesion? - Contrasting patterns
- Compliance to medication (AED)?
Approach to Seizures in Children

Birth/Growth/Development
- Developmental delay – must ask FULLY, milestones throughout growth
- Behavioural issues
- Antenatal/perinatal issues
 Premature?
 Birth trauma, asphyxia - APGAR score
 Antenatal/Childhood infections – fever, had to take antibiotics?
 Stroke/trauma

Past Medical History

- Previous seizures
- Diagnosed epilepsy
 Compliance to medications?
 Triggers?
 Typical seizure profile? (type/trigger/intervention) – important for breakthrough
- Cardiac disease
- History of bleeding disorders (coagulopathy, thrombocytopenia)
- Immunizations
- Medications – AEDs (monotherapy? Dose? Any recent changes? Any side effects?)
- Drug allergies (especially SJS/TEN) – any genetic testing done?

Family History
- Seizures, epilepsy
- Cardiovascular disease, arrhythmias

Physical Examination
Vital Signs
- Temperature
- HR, BP, RR
- GCS

General Inspection
- Growth, head circumference
- Hydration status (mucosa, skin turgor, fontanelle)
- Bulging fontanelle (raised ICP)
- Scalp haematoma
- Neck stiffness (meningism)
- Neurocutaneous stigmata (tuberous sclerosis, neurofibromatosis, Sturge-Weber)
- Syndromic features
- Rashes

Neurological Examination
- Pupil size and symmetry
- Fundoscopy: papilloedema
- Eye movements
- Muscle tone, power, reflexes, Babinski

Systemic Examination
- Heart: murmurs, heart rhythm
- Lungs: crepitations, wheezing, respiratory distress
- Abdomen: tenderness
Approach to Seizures in Children

- Ears: otoscopy
- Throat: injection, ulcers
- Rashes
- Joint pain, swelling

Investigations
- Biochemical
 FBC
 Renal panel, calcium/magnesium, liver panel
 Blood glucose
 Blood AED levels (only for patients on known AEDs, esp in suspected non-compliance)
 +/- ABG
 UFEME
- Radiological
 ECG
 EEG
 When not in seizure: may show abnormal discharge, suggesting a predisposition to
seizures (ie. idiopathic epilepsy)  but this is not diagnostic; requires clinical correlation
of 2 or more seizures
 CT/MRI brain: for focal seizures
- Invasive
 Lumbar puncture: CSF analysis and culture, bacterial cultures, viral serology 

Management
- ABCs & vitals
- Test response
 Call name
 Visual/ tactile stimulation
 Ask patient to do something specific e.g. lift hand
 Tell patient to remember a response etc CAT
- Management of fever
 Antipyretics
 Non-pharmacological management
- Management of underlying infection
- Management of recurrent seizure (see status epilepticus)
 Attempt to obtain IV access
 Take bloods (H/C, RP, Ca, Mg)
 If hypoglycemic (<3mmol/L), give dextrose
 Benzodiazepines (initial management)
 No IV access
 PR diazepam/Valium 0.4mg/kg, max dose 10mg/dose
 Repeat dose x1 in 5mins if not aborted
 IV access
 IV diazepam/Valium 0.25mg/kg, max dose 10mg/dose
 IV lorazepam 0.1mg/kg, max dose 4mg/dose
 Repeat dose x1 in 5mins if not aborted
 Anti-epileptics  after x2 doses of BZDs 5mins apart w/o seizure abortion
 IV phenobarbitone (if <1yo)
 IV phenytoin
 If not aborted, transfer to ICU for anesthesia under EEG monitoring
Approach to Seizures in Children

Epilepsy advice + precautions

- 1st ep of afebrile seizure40% chance of recurrence
- What to do if future seizure(s)/status epilepticus
- Swimming: MUST be supervised, wear floats etc.
- Avoid activities involving heights
 If need be, wear a harness, safety mechanisms
- Avoid contact sports
- Supervised play wherever possible
- Electric scooters, skateboards, bicycles
 Use helmets, padding, do it in the park and not along the roads
- No driving

Benign Rolandic Epilepsy with centro-temporal spikes (BECTS)

- Most common childhood epileptic disorder (15%)
- Clinical features:
 Onset: 2-14years, peaks 9-10years
 Pre-seizure:
 Usually during sleep
 Triggered by sleep deprivation
 Seizure: focal seizure, lasts <2min
 Salivation, drooling, motor speech arrest
 +/- Secondary generalisation e.g. Grand Mal seizures may occur
 Post-seizure: often wakes up, if not may be hypnic jerk
- PE: Normal development, neuro exam (required for diagnosis)
- Diagnosis:
 History
 EEG: centrotemporal spikes
 +/- MRI: usually not needed if Hx and EEG consistent
- Management
 If frequent, causing learning difficulties Na valproate, CBZ, LTG
- Prognosis: excellent
 Almost all stop on their own by 15 years

West syndrome
- Incidence:
 1-in-4000 births
 Peak at 3-7 months of age
- Clinical presentation: triad of
 Infantile spasm (myoclonic jerks)
 Several clusters a day
 Flexor/ extensors/ mixed
 Can be focal/ generalised
 Visual inattention, axial hypotonia can precede seizure
 Neurodevelopmental delay/ regression
 Hyperarrhythmias on EEG (chaotic)
- Causes
 Neurocutaneous syndromes e.g. tuberous sclerosis, Sturge-Weber, NF
 Metabolic disorders e.g. phenylketonuria, maple syrup urine
 Perinatal/postnatal insults e.g. HIE, IVH, trauma, TORCH
 5% idiopathic
Approach to Seizures in Children

- Ix
 EEG
 MRI brain
- Management
 Corticosteroids or vigabatrin
 ACTH
 AEDs
 Focal cortical dysplasia: multilobar resection

Lennox-Gastaut syndrome
- Onset: 1-14 years
- Severe epileptic disorder with multiple concurrent seizure types (myoclonic, absence, tonic,
GTC), cognitive dysfunction
- EEG: diffuse slow spikes and waves with an abnormally slow background
- POOR PROGNOSIS (both seizure control and mental development)

Childhood absence epilepsy

- Onset 3-10 years, peak age of 6-7 years
- Strong hereditary disposition: 40% of 1st degree relatives affected
- Clinical features
 Pre-seizure: Induced by hyperventilation, strong emotions or hunger
 Seizure: brief episode of staring with unresponsiveness
 Post-seizure: no post-ictal phase

Status epilepticus management

- Definition: seizure >30 minutes or repeated frequently without gaining consciousness between
seizures
Approach to Seizures in Children

*Phenytoin: monitor ECG for arrhythmia

**Phenobarbitone: monitor SpO2 for respiratory depression as well

Simple Febrile Seizures

See Approach to Child with Fever