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Seizures

What Are Seizures

Seizures are repetitive discharges in the brain. Most of the time seizures result in involuntary jerking of the arms or legs or other movements referred to as “motor” activity. These “motor” seizures are what most people think of when they think of “seizures”, “convulsions” or “fits”. However, less common seizure types may result in more complex behavioral changes, inactivity, or even abnormal perceptions.

Types of Seizures

  • Absence Seizures (a.k.a. Petit Mal) : Short staring spells (loss of consciousness, but will maintain postural tone (i.e. remain standing), no breathing problems.
  • Complex Partial Seizures (a.k.a. Temporal Lobe Seizures): Highly variable, usually involve stereotypic movements and verbalizations (alteration in consciousness, usually maintains postural tone, and generally no breathing problems).
  • Generalized Tonic Clonic Seizures (a.k.a. Grand Mal): Rhythmic jerking of all extremities (loss of consciousness, loss of postural tone, and may have inadequate breathing).
  • Simple Partial Seizures (a.k.a. Focal Motor Seizures): Rhythmic jerking, usually of a single body part but may spread, staying on one side of the body (no loss of consciousness, no loss of postural tone, no respiratory problems).
  • Newborn Seizures: Newborns have reflexes such as the Moro reflex (the startle reflex), as well as normal occasional muscle twitches called myoclonic jerks. However, true seizures also may occur in newborns. Prolonged jerking, sucking, lip smacking, horizontal eye deviation and apnea all are suspicious and should prompt evaluation.
  • Infantile Spasms (a.k.a. Salaam Spells) : Clusters of spasms-usually consisting of the infant involuntarily bending forward and bringing the arms forward, bending at the elbow. This motion appears as though the infant is grabbing a great big invisible sphere. Many cases are associated with poor intellectual outcome. The diagnosis is confirmed with EEG. Often treatment includes steroids or adrenocorticotropic hormone.
  • Status Epilepticus: Any prolonged seizure, or two seizures within a fifteen minute period. The seizure may be of any type.

What is epilepsy?

Epilepsy is a seizure disorder which is not caused by an acquired illness. In other words, a child may have a single seizure associated with: a fainting spell; following head trauma; a febrile illness; or as part of another illness. In most of these cases the child will never have another seizure. This is not epilepsy. In other cases, very frequent seizures may not be referred to as epilepsy because they are due to meningitis, brain tumor, stroke or another identifiable acquired cause.

Epilepsy probably encompasses many different disorders, the depths of which medical science has not fully plumbed. However, some are probably caused by metabolic disorders, others by migrational defects (small areas of “gray matter” which belong on the outer layer of the brain are instead mixed in with the “white” matter).

Evaluation of children with seizures

New onset seizure: All cases of new onset of a seizure require evaluation. If your child’s physician or the emergency room physician is able to identify a cause (e.g. a febrile seizure), the evaluation may be limited. In other cases extensive blood test, spinal tap, electroencephalogram (EEG), and imaging (e.g. MRI or CT scan may be required). Sometimes a neurologist or child neurologist will need to be involved.

In children with known epilepsy or seizure disorders: Given the advances in diagnostics and anticonvulsant therapeutic options, these children should be followed by a pediatric neurologist. In certain rural settings this may not be possible, so an adult neurologist who has experience in treating children may suffice. Alternatively, day by day management by a family practice physician or pediatrician, which is overseen by a pediatric neurologist who knows the child and can see the child on a perhaps less regular basis, is another option.

At regular intervals your child should be seen in the physician’s office to evaluate the effect of the current medication regimen, look for side effects of medication and look for any changes in the underlying disorder. A seizure diary should be kept so that benefit or lack of benefit of anticonvulsant medications can be clearly established.

In the setting of a known seizure disorder, is not practical or necessary to engage in evaluation of every seizure. However, if there is a change in seizure type, or a change in frequency of seizures, you should consult with your child’s physician.

Treatment of Seizures

Seizure disorders may spontaneously resolve, or may be lifelong problems. Especially in the latter cases, it is important to try to maintain as normal a lifestyle as possible. This includes not avoiding public situations for fear of seizures, and not avoiding most physical activities. However certain adjustments must usually be made. The specifics of these should be discussed with your child’s physician.

The mainstay of therapy is the use of anticonvulsant medications. However, fever lowers the brain’s threshold to have a seizure, thus, aggressive use of antipyretics during febrile episodes is also important ( and in the case of febrile seizures usually the focus of treatment). Occasionally, counseling or treatment of depression is necessary. Rarely, dietary therapy (a ketogenic diet) may also be instituted.

Commonly used anticonvulsants…

The specific uses and common side effects are beyond the scope of this section. Although most of the listed medications cause some degree of drowsiness or fatigue, several can effect the liver and bone marrow.  Often, the oral liquid “syrup” preparations of these medications do not mix well and it is necessary to find creative ways to have children take crushed tablets, or sprinkled capsule contents mixed with food. Ask your child’s physician about the specifics of any medication which your child is taking.

  • Carbamazepine (Tegretol)
  • Clobazam
  • Clonazepam (Klonopin)
  • Diazepam (Valium)- drowsiness limits its use to status epilepticus and sometimes rectal use in frequent febrile seizures.
  • Ethosuximide (Zarontin)- used mainly for absence type seizures.
  • Gabapentin (Neurontin)
  • Lamotrigine (Lamictal)
  • Lorazepam (Ativan)- used mainly for status epilepticus
  • Paraldehyde-used rarely for status epilepticus
  • Phenobarbitol- used frequently in newborns, limited used in other groups because of drowsiness except for status epilepticus.
  • Phenytoin (Dilantin)- Dilantin is a versatile and useful medication in the short run, if prolonged use is contemplated, consideration of an alternative should be considered because of Dilantin’s side effect profile. Prolonged use is associated with enlargement of the gums, skin rashes, excess hair growth, and liver damage.
  • Primidone (Mysoline)- primidone is an anticonvulsant itself, but also is metabolized to phenobarbital.
  • Topiramate (Topimax)
  • Tiagabine (Gabitril)
  • Valproic acid (Depakene, Epival Depakote)- for younger children who cannot take pills, the Depakote sprinkles are often preferred because the Depakene syrup tends not to mix evenly.