1. The Child with Fits
Lydia Burland

2. Learning Outcomes By the end of the session you should;
Know of the common causes of seizure, including febrile fits and childhood epilepsy syndromes
Be able to explain to parents pathophysiology, as well as further investigation and management
Be able to manage seizures acutely
Be able to answer questions on the topic

3. Childhood Seizures 600,000 people with epilepsy in the UK
Inappropriate sensory or motor activity due to abnormal signalling in the brain
Causes include;
Primary epilepsy Cranial malformation
Infection Trauma/injury
Fever Space occupying lesions
Syncope Electrolyte abnormality

4. Childhood Seizures Focal seizures: Generalised seizures:
seizure activity in a localised part of the brain with no loss of consciousness (LOC)
most commonly arising from the temporal and frontal lobes
Generalised seizures:
seizure activity throughout both hemispheres, associated with LOC
types of generalised seizure include tonic-clonic, tonic, atonic, myoclonic and absence

5. Acute Management
Airway: recovery position or airway adjuncts Breathing: O2 if needed Circulation: get IV access and take bloods Dysfunction: CBG, GCS and pupils Expose: looking for causes of the seizure

6. Acute Management With IV Access Without IV Access 0 mins Lorazepam
Buccal midazolam
>10 mins
Paraldehyde (not if unsuccessful previously)
>20 mins
Phenytoin
OR (if on phenytoin)
Phenobarbital AND (if <3yrs with afebrile status) Pyridoxine
Call for senior help
Secure intraosseous access
>40 mins
PICU input
Consider thiopental rapid sequence induction

7. Long-term Management If a patient presents with a seizure you should;
Take a full history
Examine fully, including CNS/PNS
If suspicious for epilepsy refer to neurology clinic
Arrange an outpatient EEG +/- imaging
Once a diagnosis is made a neurologist will decide if treatment is needed

8. Advice for Patients and Parents
Once a diagnosis of epilepsy has been made you should advise;
Patients should not lock the bathroom door when taking a bath
Patients should wear a helmet when riding a bike
Inform lifeguards of their diagnosis if going swimming
That epileptic patients cannot drive unless fit-free for a year

9. Non-Epileptic Attacks

10. Febrile Convulsions
Convulsion associated with high fever, in the absence of another cause
Affect 2-4% of children
Most common between 6 months and 6 years
Positive family history in around 25%
Aetiology is unclear, common precipitants include viral illness, otitis media and tonsilitis
Peak incidence at 18 months

11. Febrile Convulsions Simple convulsions are;
tonic-clonic
last less than minutes
do not recur within the same illness
Complex convulsions may start focally, last longer than 15 minutes, or recur
Febrile status occurs in 5%
Peak incidence at 18 months

12. Febrile Convulsions May not need further investigation
Treat with antipyretics if the child is distressed, +/- antibiotics for the causative infection
If any doubt about the cause of the seizure a full septic screen should be performed
Treat with broad spectrum IV abx if the origin of infection is not known
Reassure parents and teach them how to manage further seizures
What does a full septic screen include?
Bloods (FBC/U+E/LFTs/CRP/glucose/cultures)
CXR
Urine dip +/- MSU LP
Discussion with parents should be reassuring – the seizure is thought to be due to the fever, and not due to an underlying abnormality or epilepsy. If it has been a simple convulsion there is no increased risk of developing epilepsy later in life.
You should also warn parents that seizures may recur (30%), either in this illness or in subsequent illnesses. You should teach parents how to manage seizures by placing the child in the recovery position, and instruct them to come to hospital if ny abnormal features or if the seizure lasts longer than 5 minutes.

13. Reflexic Anoxic Attacks
Brief episodes of asystole triggered by pain, fear or anxiety
The child becomes suddenly pale, limp and loses consciousness, followed by a tonic-clonic phase
Episodes usually resolve in 30-60seconds, after which children may feel tired
These are non-epileptic events
Can occur at any age, but most common between 6 months and 2 years or age

14. Reflexic Anoxic Attacks
Diagnosis is usually based on the history, with a normal ECG and EEG
Once a diagnosis has been made parents should be reassured
If further attacks occur the child should be placed in the recovery position
The majority of children grow out of attacks, though they may recur later in life

15. Childhood Epilepsy Syndromes

16. Case 1
Toby is brought to see his GP as school are complaining that he is ‘day-dreaming’ in class
It happens around times a day
He is otherwise developmentally normal
Mum says his dad use to ‘day-dream’ when he was younger
What is the most likely diagnosis?

17. Case 1: Childhood Absence Epilepsy
Onset between 3-12 years of age
Frequent absence episodes lasting 5-20 seconds
May have associated ‘automatisms’ such as eyelid flickering and lip-smacking
Child is otherwise normal and there is often a positive family history
Seizures remit in adolescence without treatment
The use of carbemazepine can increase seizure frequency
AED of choice: sodium valproate (epilim)

18. Case 2
A 15 year old girl is brought into A+E after she experiences a tonic-clonic seizure
She was at a family party until late last night, where she did not drink any alcohol or use any illicit drugs
She had a similar episode after a sleep-over last month which has not been investigated
Her mum says she is clumsy and often drops things when getting breakfast ready in the morning
What is the most likely diagnosis?

19. Case 2: Juvenile Myoclonic Epilepsy
Onset between 8-26 years, more common in girls
Characterised by;
Early morning myoclonic jerks of the upper limbs
Tonic-clonic seizures provoked by sleep deprivation
Absence seizures
May be triggered by flashing lights (40%), sleep deprivation and alcohol
The majority are well controlled with anti-epileptics, which may need to be taken lifelong
AED of choice: sodium valproate (epilim)

20. Case 3
A 9 year old presents with frequent episodes of salivation and aphasia during the night, he is awake throughout and appears upset
His mum says she has noticed some facial twitching during these episodes
He is otherwise fit and well, and has had no day time symptoms
What is the most likely diagnosis?
What would you tell his parents regarding prognosis?

21. Case 3: Benign Rolandic Epilepsy
Onset between 3-12 years, peak at 9 years
Nocturnal, benign seizures
Unilateral paraesthesia of the face, with ipsilateral facial motor seizure
No LOC but unable to speak, and often salivation
Last around 1-2 minutes
Day time seizures are rare
Seizures resolve during puberty without treatment
AEDs of choice (rarely needed): carbemazepine (tegretol), lamotrigine and sodium valproate

22. Case 4
A 3 year old presents with episodes where he repeatedly flexes his trunk forcefully and throws his arms up
His mum has also noted that he;
Is less steady on his feet
Can no longer draw or use a fork and spoon
An EEG shows asynchronous spikes on a chaotic background
What type of seizure is described?
What is the most likely diagnosis?
Type of seizure: infantile spasm
Diagnosis: Lennox-Gastaut syndrome

23. Case 4
A 3 year old presents with episodes where he repeatedly flexes his trunk forcefully and throws his arms up
His mum has also noted that he;
Is less steady on his feet
Can no longer draw or use a fork and spoon
An EEG shows asynchronous spikes on a chaotic background
What type of seizure is described? Infantile spasm
What is the likely diagnosis? Lennox-Gastaut Syndrome
Type of seizure: infantile spasm
Diagnosis: Lennox-Gastaut syndrome

24. Case 4: Lennox-Gastaut Syndrome
Triad of;
Infantile spasms
Motor regression
Typical EEG pattern
Poor prognosis with 5% mortality
Survivors have severe developmental delay and persistent seizures
Vigabatrin, steroids and ACTH can be used to control infantile spasms

25. EMQ Questions

26. Questions Febrile fit b. Reflexic anoxic attack
c. Absence seizure d. Benign Rolandic
e. Infantile spasm f. Juvenile myoclonic
An 18 month old is playing with her brother when she bumps her head on a door frame. She suddenly drops to the floor and twitches her arms and legs for 1 minute. When she comes round she is drowsy but otherwise well.

27. Questions Febrile fit b. Reflexic anoxic attack
c. Absence seizure d. Benign Rolandic
e. Infantile spasms f. Juvenile myoclonic
2. A 9 month old boy has had clusters of episodes where he flexes his trunk and spreads his arms out. These happen in the morning, and is otherwise developmentally normal.

28. Questions Febrile fit b. Reflexic anoxic attack
c. Absence seizure d. Benign Rolandic
e. Infantile spasms f. Juvenile myoclonic
3. A 13 year old girl has had isolated muscle spasms for the last few weeks, she initially ignored them but is now annoyed as she keeps spilling drinks. She is otherwise well.

29. Questions Tonic-clonic b. Atonic c. Absence d. Myoclonic
e. Focal (frontal lobe) f. Focal (temporal lobe)
4. An 8 year old is in class when her teacher notices she is not responding to voice, and is chewing her lips repetitively.

30. Questions Tonic-clonic b. Atonic c. Absence d. Myoclonic
e. Focal (frontal lobe) f. Focal (temporal lobe)
5. A 7 year old boy presents with several episodes where he smells ‘something funny’ and feels nauseated, before several minutes of lip smacking.

31. Questions Tonic-clonic b. Atonic c. Absence d. Myoclonic
e. Focal (frontal lobe) f. Focal (temporal lobe)
6. A 5 year old boy suffers from frequent ‘drop’ attacks that come on without warning. He suddenly drops to floor, then recovers spontaneously without any memory of the event.

32. EMQ Answers

33. Answers Febrile fit b. Reflexic anoxic attack
c. Absence seizure d. Benign Rolandic
e. Infantile spasm f. Juvenile myoclonic
An 18 month old is playing with her brother when she bumps her head on a door frame. She suddenly drops to the floor and twitches her arms and legs for 1 minute. When she comes round she is drowsy but otherwise well.

34. Answers Febrile fit b. Reflexic anoxic attack
c. Absence seizure d. Benign Rolandic
e. Infantile spasms f. Juvenile myoclonic
2. A 9 month old boy has had clusters of episodes where he flexes his trunk and spreads his arms out. These happen in the morning, and is otherwise developmentally normal.

35. Answers Febrile fit b. Reflexic anoxic attack
c. Absence seizure d. Benign Rolandic
e. Infantile spasms f. Juvenile myoclonic
3. A 13 year old girl has had isolated muscle spasms for the last few weeks, she initially ignored them but is now annoyed as she keeps spilling drinks. She is otherwise well.

36. Answers Tonic-clonic b. Atonic c. Absence d. Myoclonic
e. Focal (frontal lobe) f. Focal (temporal lobe)
4. An 8 year old is in class when her teacher notices she is not responding to voice, and is chewing her lips repetitively.

37. Answers Tonic-clonic b. Atonic c. Absence d. Myoclonic
e. Focal (frontal lobe) f. Focal (temporal lobe)
5. A 7 year old boy presents with several episodes where he smells ‘something funny’ and feels nauseated, before several minutes of lip smacking.

38. Answers Tonic-clonic b. Atonic c. Absence d. Myoclonic
e. Focal (frontal lobe) f. Focal (temporal lobe)
6. A 5 year old boy suffers from frequent ‘drop’ attacks that come on without warning. He suddenly drops to floor, then recovers spontaneously without any memory of the event.

39. In Summary
Seizures in childhood are caused by many different mechanisms
The diagnosis often unclear following the 1st episode, a good history is the basis of diagnosis
Investigations include EEG and brain imaging
Prognosis is dependent upon the cause – some seizures are benign, whilst others need life-long treatment
Is it important to communicate clearly with parents and advise appropriately

40. Any questions?
Lydia Burland