Seizures in Children Dr Penny Mancais Consultant Paediatrician Dorset County Hospital Foundation trust

To be Covered Terminology History taking Prognosis of Seizures Fits, faints and funny turns When to refer Pragmatic advice in Epilepsy

ANY SUDDEN ATTACK FROM WHATEVER CAUSE. Definition of Seizure ANY SUDDEN ATTACK FROM WHATEVER CAUSE. Many manifestations determined by site of origin. Many causes: Non Epileptic (reflex anoxic ,fainting, Tics ,migraines, night terrors ) Epileptic altered consciousness,involuntary movement,changes in behaviour etc. Convulsion/fit also used but best avoided. Epileptic seizure implies attack has occurred of epileptic activity in the brain Febrile seizue between 3/12-6years with fever but no intracranial infection or defined cause. No definition of fever but temp at least 37.8 (NIH in America)

Definition of Epileptic Seizure Manifestation of Epileptic (excessive) usually self limited activity of neurons in the brain ILAE Only use seizure or epileptic seizure. Febrile seizure causes an epileptic seizure but child does not have epilepsy Epilepsy involves recurrent epileptic activity and is unprovoked ie no fever or no glucose.

Prognosis of seizures 1% afebrile seizure 3% febrile seizure 50% will have a recurrence 3% febrile seizure Risk of recurrence 35% Risk of Epilepsy following simple 1% Risk of Epilepsy following complex 6% Risk of Epilepsy following complex/FH 30% Complex is >15mins,focal multiple in 24hrs.

Taking the History Diagnosis is in the History No Ix to confirm epilepsy RELIANT ON HISTORY True for faints, night terrors EEG does not diagnose. 1\3rd patients misdiagnosed around the country including centres of excellence in Zurich. As Gps do not need to diagnose epilpepsy but a clear history will help you decide?night terror, reflex anoxic seizure or unexplained.

What to ask Eye witness account Role play Avoid interpretations Time line Use counting Home videoing Pick up the phone speak to person who saw it. Takes time need to allow 15mins for a good detailed account Time line-onset,freq,when they occur, initial features,following duration

Features that may occur in Seizures Sudden fall Jerking limbs Blank stare Urinary incontinence Funny smell Feeling of fear Facial flushing Seeing coloured spots vomiting Racing heart Tingling sensations Headache Generalised stiffening Floppiness Ringing noises Hiccups Sudden loss of vision Epilepsy or otherwise. 50% of children have faints sitting down Jerks and wetting can occur in faints Recovery can be quick in all epileptic and non epileptic seizures ? Confused order I n which things happy is important

Fits Faints and funny turns Collapsing with convulsions Drop attacks Stiffening attacks During sleep Epileptic and non epileptic causes of both Syncope ,RAS, psychogenic or GTCS Astatic epilepsy, vertigo, cataplexy, episodic ataxia Psychogenic self gratification tonic seizures Epilepsy,night terrors, night mares, myoclonus

Fits faints and funny turns Appendix f of the NICE guideline History differential diagnosis in different age groups.

When to refer Any child with ‘unexplained seizure’ (NICE) <1years discuss ?admit NO investigations Advise home videoing, diary monitoring All children with a diagnosis of epilepsy should have a named paediatrician. Pick up phone discuss with COW or send urgent fax. Do not feel we can do within 2 weeks at present. NO investigations EEG can be abnormal in those without epilepsy and noraml in those with. No blodd tests (obviously glusoes if child having a seizure)

Pragmatic advice in Epilepsy Will my child die? Risk from fit is negligible SUDEP 1:200 (poor control,teenagers,male) Accidents NO climbing/harness, swimming 1:1, shower Alcohol (1=3 on anticonvulsants) Recreational drugs (increase risk of seizure) Most seizures last less than 2 mins if >5mins less likely to stop.Rectal diazepam for frequent or prolonged febrile convulsions. Buccal midazolam for epilpetics NO climbing with out harness for any form of seizure. SUDEP no risk in idiopathic generalised epilepsy)

Advice continued Contraception: Higher doses of Oestrogen for enzyme inducing drugs plus barrier protection Starting a family Driving Nocturnal seizures ok Fit free 1yr on/off medication DVLA latest advice Pill and lamotrigine(need increased dose of lamotrigine Mini pill no good Many issues for women who are preganant ideally talk through before coming pregnant.

Medication Now 17 drugs available Aim to improve seizure control Minimises effects on learning and behaviour Blood tests not needed Very little evidence causes long term prognosis or alters death Only to see if in therapeutic range/compliant

Summary History, History, History All children with unexplained seizure need referral <1 pick up phone ? Admit Web sites: National Society for Epilepsy Epilepsy action The future-hospital guideline for management of first seizure in secondary care Bid for Epilepsy nurse partic the transition years. Thank you questions