Seizures in Children

Some seizures in children will not need emergency treatment.

A seizure occurs when the brain functions abnormally, resulting in a change in movement, attention, or level of awareness. Different types of seizures may occur in different parts of the brain and may be localized (affect only a part of the body) or widespread (affect the whole body). Seizures may occur for many reasons, especially in children. Seizures in newborns may be very different than seizures in toddlers, school-aged children, and adolescents. Seizures, especially in a child who has never had one, can be frightening to the parent or caregiver.

• A low percentage of all children have a seizure when younger than 15 years, half of which are febrile seizures (seizure brought on by a fever). One of every 100 children has epilepsy-recurring seizures.
• A febrile seizure occurs when a child contracts an illness such as an ear infection, cold, or chickenpox accompanied by fever. Febrile seizures are the most common type of seizure seen in children. Two to five percent of children have a febrile seizure at some point during their childhood. Why some children have seizures with fevers is not known, but several risk factors have been identified.
• Children with relatives, especially brothers and sisters, who have had febrile seizures are more likely to have a similar episode.
• Children who are developmentally delayed or who have spent more than 28 days in a neonatal intensive care unit are also more likely to have a febrile seizure.
• One of 4 children who have a febrile seizure will have another, usually within a year.
• Children who have had a febrile seizure in the past are also more likely to have a second episode.
• Neonatal seizures occur within 28 days of birth. Most occur soon after the child is born. They may be due to a large variety of conditions. It may be difficult to determine if a newborn is actually seizing, because they often do not have convulsions. Instead, their eyes appear to be looking in different directions. They may have lip smacking or periods of no breathing.
• Partial seizures involve only a part of the brain and therefore only a part of the body.
• Simple partial (Jacksonian) seizures have a motor (movement) component that is located in one portion of the body. Children with these seizures remain awake and alert. Movement abnormalities can "march" to other parts of the body as the seizure progresses.
• Complex partial seizures are similar, except that the child is not aware of what is going on. Frequently, children with this type of seizure repeat an activity, such as clapping, throughout the seizure. They have no memory of this activity. After the seizure ends, the child is often disoriented in a state known as the postictal period.
• Generalized seizures involve a much larger portion of the brain. They are grouped into 2 types: convulsive (muscle jerking) and nonconvulsive with several subgroups.
• Convulsive seizures are noted by uncontrollable muscle jerking lasting for a few minutes-usually less than 5-followed by a period of drowsiness that is called the postictal period. The child should return to his or her normal self except for fatigue within around 15 minutes. Often the child may have incontinence (lose urine or stool), and it is normal for the child not to remember the seizure. Sometimes the jerking can cause injury, which may range from a small bite on the tongue to a broken bone.
• Tonic seizures result in continuous muscle contraction and rigidity, while tonic-clonic seizures involve alternating tonic activity with rhythmic jerking of muscle groups.
• Infantile spasms commonly occur in children younger than 18 months. They are often associated with mental retardation and consist of sudden spasms of muscle groups, causing the child to assume a flexed stature. They are frequent upon awakening.
• Absence seizures, also known as petit mal seizures, are short episodes during which the child stares or eye blinks, with no apparent awareness of their surroundings. These episodes usually do not last longer then a few seconds and start and stop abruptly; however, the child does not remember the event at all. These are sometimes discovered after the child's teacher reports daydreaming, if the child loses his or her place while reading or misses instructions for assignments.
• Status epilepticus is either a seizure lasting longer than 30 minutes or repeated seizures without a return to normal in between them. It is most common in children younger than 2 years, and most of these children have generalized tonic-clonic seizures. Status epilepticus is very serious. With any suspicion of a long seizure, you should call 911.
• Epilepsy refers to a pattern of chronic seizures of any type over a long period. Thirty percent of children diagnosed with epilepsy continue to have repeated seizures into adulthood, while others improve over time.

Seizures in children have many different types of symptoms. A thorough description of the type of movements witnessed, as well as the child's level of alertness, can help the doctor determine what type of seizure your child has had.

• The most dramatic symptom is generalized convulsions. The child may undergo rhythmic jerking and muscle spasms, sometimes with difficulty breathing and rolling eyes. The child is often sleepy and confused after the seizure and does not remember the seizure afterward. This symptom group is common with grand mal (generalized) and febrile seizures.
• Children with absence seizures (petit mal) develop a loss of awareness with staring or blinking, which starts and stops quickly. There are no convulsive movements. These children return to normal as soon as the seizure stops.
• Repetitive movements such as chewing, lip smacking, or clapping, followed by confusion are common in children suffering from a type of seizure disorder known as complex partial seizures.
• Partial seizures usually affect only one group of muscles, which spasm and move convulsively. Spasms may move from group to group. These are called march seizures. Children with this type of seizure may also behave strangely during the episode and may or may not remember the seizure itself after it ends.

Although seizures have many known causes, for most children, the cause remains unknown. In many of these cases, there is some family history of seizures. The remaining causes include infections such as meningitis, developmental problems such as cerebral palsy, head trauma, and many other less common causes.

About 25% of the children who are thought to have seizures are actually found to have some other disorder after a complete evaluation. These other disorders include fainting, breath-holding spells, night terrors, migraines, and psychiatric disturbances.

The most common type of seizure in children is the febrile seizure, which occurs when an infection associated with a high fever develops.

Other reasons for seizures include:

• Infections
• Metabolic disorders
• Drugs
• Medications
• Poisons
• Disordered blood vessels
• Bleeding inside the brain
• Many yet undiscovered problems

A large portion of seizures in childhood can be grouped into the following categories:

• Myoclonic: A seizure characterized by jerking, spasming muscle groups with no loss of consciousness
• Myoclonic absences: A seizure characterized by spasming muscle groups with brief loss of consciousness
• Myoclonic tonic seizures: The seizure includes jerky muscle spasms and motionless spasms that cause rigidity.
• Other seizure disorders in children are not discussed here

Seizure disorders in infancy and early childhood often are caused by a genetic mutation, but a significant percentage of children with seizure disorders don’t readily fit into established disorders and diagnoses – the cause is a mystery. The following are some types of myoclonic seizure disorders in children:

Early infantile epileptic encephalopathies: This includes early myoclonic encephalopathy (EME) and early infantile epileptic encephalopathy (EIEE). These are severe disorders with a grave prognosis.

Causes of early infantile epileptic encephalopathies include brain malformations, inborn errors of metabolism, and neurogenetic disorders.

Myoclonic epilepsy occurring as part of a mixed generalized epilepsy syndrome: This includes:

• Doose syndrome (myoclonic-atonic epilepsy)
• Lennox-Gastaut syndrome
• Dravet syndrome (severe myoclonic epilepsy of infancy)
• Progressive spasticity is frequently seen in older children and adolescents with Dravet syndrome, often associated with the development of crouched gait or walk.
• Causes may include brain malformation and mutations that cause neurons to malfunction, such as SCN1A mutations.
• Other syndromes that feature several kinds of generalized seizures are also included in this classification.

Nonprogressive myoclonic epilepsies: This group of disorders overall has a more favorable prognosis and includes:

• Benign neonatal myoclonic epilepsy,
• Familial myoclonic epilepsy, and
• Autosomal dominant cortical myoclonus and epilepsies.

Nonprogressive myoclonic encephalopathies may also occur, with a worse prognosis. These disorders are usually genetically determined conditions.

Progressive myoclonic epilepsies: In this class of myoclonic epilepsies, seizures occur in the context of an underlying neurodegenerative disorder. Representative diseases include:

• Unverricht-Lundborg disease
• Lafora body disease
• Myoclonic epilepsy with ragged red fibers (MERRF)
• The neuronal ceroid lipofuscinosis, sialidosis, and dentate-rubral-pallidoluysian atrophy (DRPLA).

Seizures in the context of these disorders may be stimulus-sensitive or action-induced.

According to the CDC, in 2015 470,000 children in the US has experienced seizures. A small percentage of all children have a seizure when younger than age 15. One-half of the seizures in children are febrile seizures (seizure brought on by a fever). Only one of every 100 children has epilepsy-recurring seizures.

Take the child to the emergency department or call 911 if you are concerned that your child was injured during the seizure or if you think that he or she may be in status epilepticus (seizures of any kind that do not stop).

Any child with repeated or prolonged seizures, trouble breathing, or who has been significantly injured should go to the hospital by ambulance.If the child has a history of seizures and there is something different about this one, such as duration of the seizure, part of body moving, a long period of sleepiness, or any other concerns, the child should be seen in the emergency department.

• All children who seize for the first time and many with a known seizure disorder should be evaluated by a doctor.
• Most children with first seizures should be evaluated in a hospital's emergency department. However, if the seizure lasted less than 2 minutes, if there were no repeated seizures, and if the child had no difficulty breathing, it may be possible to have the child evaluated at the pediatrician's office.
• After the seizure has stopped and the child has returned to normal, contact your child's doctor for further advice. Your pediatrician may recommend either an office or an emergency department visit. If you do not have a pediatrician or none is available, bring the child to the emergency department. If you are worried about possible absence seizures, evaluation at the pediatrician's office is appropriate.
• Caregivers of children with epilepsy should contact the child's pediatrician if there is something different about the type, duration, or frequency of the seizure. The doctor may direct you to the office or to the emergency department.

For all children, a thorough interview and examination should occur. It is important for the caregiver to tell the doctor about the child's medical history, birth history, any recent illness, and any medications or chemicals that the child could have been exposed to. Additionally, the doctor asks for a description of the event, specifically to include where it occurred, how long any abnormal movements lasted, and the period of sleepiness afterward. A wide variety of tests can be performed on a child who is thought to have seizures. This testing depends on the child's age and suspected type of seizures.

Febrile seizures

• Children should receive medication for the fever such as acetaminophen (for example, Tylenol) or ibuprofen (for example, Advil).
• Depending on the age of the child, the doctor may order blood or urine tests or both, looking for the source of the fever.
• If the child has had his or her first febrile seizure, then the doctor may want to perform a lumbar puncture (spinal tap) to test for possible meningitis. The lumbar puncture should be performed in children younger than 3 months, and some doctors perform them in children as old as 18 months.
• Most children do not get a CT scan of the head, unless there was something unusual about the febrile seizures, such as the child not returning to his or her normal self shortly afterward.
• Very few children with febrile seizures are admitted to the hospital. The treatment for febrile seizures is keeping the temperature down, and possibly a medication if a specific infection is found such as an ear infection. Follow up with the child's doctor in a few days.

Movement seizures

• Movement seizures, which include partial seizures and generalized (grand mal) seizures, can be very dramatic. If the child is having a seizure in the emergency department, he or she is given medications to stop the seizure.
• If the child has returned to normal in the hospital, then the child will probably have a few tests performed. Blood is drawn to check the child's sugar, sodium, and some other blood chemicals.
• If the child is on antiseizure medications, then the medication's levels in the blood are checked (if possible).
• Most children undergo a CT scan or MRI (studies looking at the structure of the brain), but this may be scheduled for several days later rather than in the emergency department. In children, these imaging studies are usually normal but are performed to look for unusual causes of seizure such as bleeding or tumor.
• Most children eventually undergo an EEG, which is a study looking at the brain waves or electrical activity of the brain. An EEG is almost never performed in the emergency department but is performed later.
• The child will probably be admitted if he or she is very young, has another seizure, has abnormal physical examination findings or lab test results, or if you live far from a hospital. Children in status epilepticus are admitted to an intensive care unit.
• If the child is doing well, doesn't have recurring seizures, and has a normal physical examination findings and blood test results, then the child will most likely be sent home to follow up with a pediatrician in a few days to continue the evaluation and arrange other tests, such as the EEG.

Absence seizures (petit mal)

• These can be evaluated without going to an emergency department. Most likely, the doctor will only order an EEG. If the EEG tells the doctor that the child is having absence seizures, then the child will most likely be placed on medications to control them.
• Seizures of this type occur in young children and are often associated with other problems such as mental retardation. Children suspected of having these seizures may have multiple lab tests done in the emergency department. They would include blood and urine samples, lumbar puncture, and possibly a CT scan of the head. These children are usually admitted to the hospital and may even be referred to a pediatric specialty hospital. In the hospital, these children undergo several days of testing to look for the many possible causes of the seizures.

Your initial efforts should be directed first at protecting the child from additionally injuring himself or herself.

• Help the child to lie down.
• Remove glasses or other harmful objects in the area.
• Do not try to put anything in the child's mouth. In doing so, you may injure the child or yourself.
• Immediately check if the child is breathing. Call 911 to obtain medical assistance if the child is not breathing.
• After the seizure ends, place the child on one side and stay with the child until he or she is fully awake. Observe the child for breathing. If he or she is not breathing within 1 minute after the seizure stops, then start mouth-to-mouth rescue breathing (CPR). Do not try to do rescue breathing for the child during a convulsive seizure, because you may injure the child or yourself.
• If the child has a fever, acetaminophen (such as Tylenol) may be given rectally.
• Do not try to give food, liquid, or medications by mouth to a child who has just had a seizure.
• Children with known epilepsy should also be prevented from further injury by moving away solid objects in the area of the child. If you have discussed use of rectal medication (for example, Valium) with your child's doctor, give the child the correct dose.

Treatment of children with seizures is different than treatment for adults. Unless a specific cause is found, most children with first-time seizures will not be placed on medications.

Important reasons for not starting medications:

• During the first visit, many doctors cannot be sure if the event was a seizure or something else.
• Many seizure medications have side effects including damage to your child's liver or teeth.
• Many children will have only one, or very few, seizures.
• If medications are started
  • The doctor will follow the drug levels, which require frequent blood tests, and will watch closely for side effects. Often, it takes weeks to months to adjust the medications, and sometimes more than one medicine is needed.
  • If your child has status epilepticus, he or she will be treated very aggressively with antiseizure medications, admitted to the intensive care unit, and possibly be placed on a breathing machine.

The prognosis for children with seizures depends on the type of seizures. Most children do well, are able to attend regular school, and have no limitations. The exceptions occur with children who have other developmental disorders such as cerebral palsy and in children with neonatal seizures and infantile spasms. It is important to talk with your child's doctor about what to expect with your child.

• Many children "outgrow" seizures as their brains mature. If several years pass without any seizures, doctors often stop the child's medications and see if the child has outgrown the seizures.
• A seizure in general is not harmful unless an injury occurs or status epilepticus develops. Children who develop status epilepticus have a low risk of dying from the prolonged seizure.
• Children with febrile seizures "outgrow" them, but they often have repeated seizures when they develop fevers while they are young. Some children with febrile seizures go on to have epilepsy, but most doctors believe the epilepsy was not caused by the febrile seizures.

Most seizures cannot be prevented. There are some exceptions, but these are very difficult to control, such as head trauma and infections during pregnancy.

• Children who are known to have febrile seizures should have their fevers well controlled when sick.
• The biggest impact caretakers can have is to prevent further injury if a seizure does occur.
• The child can participate in most activities just as other children do. Parents and other caretakers must be aware of added safety measures, such as having an adult around if the child is swimming or participating in any other activities that could result in harm if a seizure occurs.
• One common area for added caution is in the bathroom. Showers are preferred because they reduce the risk of drowning more than baths.