Diagnosis and Management of Seizures in Children

Educational Objectives

The goal of this program is to improve the evaluation and management of new-onset unprovoked seizures. After hearing and assimilating this program, the clinician will be better able to:

1. Use electroencephalography and magnetic resonance imaging to assess a patient with a new-onset unprovoked seizure.
2. Differentiate focal onset seizures from generalized onset seizures.
3. Choose the most appropriate medication for patients according to their seizure types and comorbidities.

Summary

Differential diagnosis: transient ischemic attack (incidence in pediatric population low); migraine with aura (focal neurologic findings); psychogenic nonepileptic seizure (in patients with history of trauma, stress, or sexual abuse); if both sides of body shaking and patient able to respond, diagnosis not seizure (involvement of both hemispheres causes unconsciousness); panic attack; syncope; infantile gratification behavior; parasomnia; true seizure

New-onset unprovoked seizure: electroencephalography (EEG) — indicated in all patients; abnormalities more likely if EEG performed close to event or in patient with sleep deprivation; hyperventilation and photic stimulation trigger abnormalities; interictal findings often normal, even in known epilepsy (do not rule out seizure); abnormal EEG more likely in generalized epilepsy; new seizures in children aged ≈3 yr usually partial (focal) onset with rapid secondary generalization, and EEG normal; imaging — not indicated if EEG reveals characteristic pattern of genetic epilepsy; required if atypical or focal features present or EEG normal

Former categories: International League Against Epilepsy (ILAE) previously classified seizures as partial onset (starting in one location) and generalized onset (may start as partial and quickly generalize); each category divided into symptomatic (something in brain causing seizure [eg, shunt, neoplasm]), cryptogenic (developmental delay with same unknown cause as seizure), and idiopathic (“benign genetic”; not associated with developmental delay, but mild school difficulties possible and often outgrown); in 2017, ILAE task force reclassified subtypes

New definition of epilepsy — former criterion (2 unprovoked seizures) still acceptable; one unprovoked seizure plus reason to believe recurrence likely also acceptable (eg, abnormal EEG or magnetic resonance imaging [MRI], features of history [eg, severe developmental delay]); start medications once diagnosis made; resolution (cure) defined as freedom from seizures for 10 yr, with no medication for previous 5 yr

New categories of seizures: origin — determines appropriate medication, possibility of surgical treatment, prognosis, and possible causes; includes focal onset (previously partial onset), generalized (starts simultaneously over entire brain), unknown onset, and focal to bilateral (eg, starts with one arm twitching; then signal spreads to entire brain [both sides of body involved; loss of consciousness]); level of awareness — includes awareness maintained, impaired awareness, awareness unknown, and total loss of awareness (generalized); focal onset — awareness full or impaired; motor or nonmotor components present; generalization possible; generalized onset — includes motor or nonmotor components (eg, absence seizure); unknown onset — features may be combined

Expanded classification: motor features — automatisms, atonic seizures, clonic seizures (stiffening), and epileptic (infantile) spasms; hyperkinetic myoclonic jerks; tonic extension; nonmotor features — autonomic symptoms (eg, aura, nausea); repetitive déjà vu (aura due to seizure or neoplasm in temporal lobe); more complex motor movements — present in generalized seizures

Causes: structural; genetic; infection; metabolic disturbance; immune dysfunction; unknown; MRI reveals structural cause (eg, neoplasm, remote stroke, dysgenesis)

Genetic types of epilepsy: idiopathic — “benign” no longer used (social problems and school issues recognized); current terms treatment-responsive and not-treatment-responsive; epileptic encephalopathy — frequent seizures affect development; children aged <12 mo generally do not “outgrow” seizures (majority present at age 4-10 mo); seizure activity causes lag in achievement of milestones; interictal EEG likely abnormal in children aged 4 to 10 mo with new-onset true seizures; appearance of seizures often atypical at age <12 mo; diagnostic value of EEG high; former idiopathic categories — generalized include childhood absence, juvenile absence, juvenile myoclonic, and generalized tonic-clonic; majority of mutations de novo; disorders not always passed to offspring; mutation often unknown; majority of seizures with genetic cause generalized; epileptic encephalopathy (continued) — epileptic activity contributes to severe cognitive and behavioral impairment that can worsen over time (eg, infantile spasms at age <12 mo); early detection and treatment may lessen developmental effects; onset at any age; results of microarray and epilepsy gene panels determine medication

Antiepileptic medications: oxcarbazepine (Trileptal) — medication of choice for partial onset seizures; carbamazepine (Tegretol) — along with oxcarbazepine, associated with rash in children of Asian descent; levetiracetam (Keppra) — medication of choice for generalized seizures because of adverse effects of other medications; can cause hyperactivity; no laboratory monitoring required; may be used with other medications, including chemotherapy drugs; zonisamide (Zonegran) — can cause hyperactivity, decrease in sweating, and dizziness; topiramate (Topamax) — can cause cognitive slowing and word-finding difficulties; approved treatment for migraines; associated with weight loss; lamotrigine (Lamictal) — mood stabilizer; carries highest risk for Stevens-Johnson syndrome (monitor patient for rash, and perform complete blood count [CBC]); valproic acid (Depakote) — rarely used mood stabilizer; teratogenic; causes weight gain, hair loss, changes in CBC and liver function, and pancreatitis

Prescribing: give oxcarbazepine and levetiracetam 20 mg/kg daily; zonisamide, topiramate, and lamotrigine 3 to 9 mg/kg daily; liquid oxcarbazepine and levetiracetam, topiramate sprinkles, and chewable lamotrigine available; Gavvala et al review — start treatment after either 1 seizure plus abnormal EEG or MRI, or 2 seizures; for focal epilepsy, use narrow- or broad-spectrum medication; for generalized epilepsy, use broad-spectrum medication (narrow-spectrum can worsen condition); levetiracetam useful when category unknown (not as effective as oxcarbazepine in focal epilepsy); titrate to therapeutic dose (consider tapering when patient seizure-free for 2 yr); if seizures continue, add second medication or consider epilepsy-monitoring unit or surgery

Lifestyle issues: seizures not dangerous, but environment may be; take showers instead of baths; do not lock bathroom door; swim only if supervised by individual trained in cardiopulmonary resuscitation and watching only epileptic child; majority of states allow noncommercial driving 6 mo after last seizure; use helmet; avoid heights, heavy machinery, sleep deprivation, drugs, alcohol, and strobe lights; consider hormonal treatment to stop menses; follow glycemic index diet; treatment during seizure — place patient on side to avoid aspiration; do not insert anything into mouth (bitten tongue bleeds copiously, but heals fast)

Sudden unexpected death in epilepsy (SUDEP): incidence highest in individuals with epilepsy for >10 yr, aged >20 yr, whose seizures began at age <10 yr, and who take >2 medications with poor control; in individual who has had only 1 or 2 seizures, incidence very low

Febrile (provoked) seizures: begin at age 5 to 6 mo and end at age 5 to 6 yr; distribution bell-shaped (do not assume diagnosis at ages at edges of curve); incidence peaks at age 18 to 30 mo; diagnosis more likely in child with normal neurologic examination and development before seizure; in child with developmental delay, fever may unmask cryptogenic epilepsy by lowering threshold of seizures; definition — temperature >100.4°F within 24 hr of seizure; provoking factors — significant illness (eg, vomiting, severe diarrhea); incidence during temperature spike higher; simple — brief seizure (<15 min); 1 seizure in 24 hr; generalized seizure (eg, versive head or eye movements lacking, both sides shaking simultaneously); no workup needed if meningitis not suspected; in child aged <1 yr, speaker recommends lumbar puncture or documentation of reason why not obtained (detection of lethargy not reliable); no treatment required; send patient home with diazepam rectal gel [Diastat] for seizures >5 min; complex — obtain EEG if complexity determined by duration or frequency; obtain MRI if complexity determined by focality; treat with diazepam rectal gel; consider low dose of oral clonazepam to prevent hospitalization, intubation, and status epilepticus or if parent upset by prolonged seizures

Readings

Fisher RS et al: Operational classification of seizure types by the International League Against Epilepsy: position paper of the ILAE Commission for Classification and Terminology. Epilepsia 2017 Apr;58(4):522-30; Gavvala JR et al: New-onset seizures in adults and adolescents: a review. JAMA 2016 Dec 27;316(24):2657-68; Glauser TA et al: Management of childhood epilepsy. Continuum (Minneap Minn) 2013 Jun;19(3 Epilepsy):656-81; Howell KB et al: Epileptic encephalopathy: use and misuse of a clinically and conceptually important concept. Epilepsia 2016 Mar;57(3):343-7; Jones LA et al: Sudden death in epilepsy: insights from the last 25 years. Seizure 2017 Jan;44:232-6; Martin K et al: Ketogenic diet and other dietary treatments for epilepsy. Cochrane Database Syst Rev 2016 Feb 9;2:CD001903; Patterson JL et al: Febrile seizures. Pediatr Ann 2013 Dec;42(12):249-54; Prasad DK et al: Genetics of idiopathic generalized epilepsy: an overview. Neurol India 2013 Nov-Dec;61(6):572-7; Scheffer IE et al: ILAE classification of the epilepsies: position paper of the ILAE Commission for Classification and Terminology. Epilepsia 2017 Apr;58(4):512-21; Tolaymat A et al: Diagnosis and management of childhood epilepsy. Curr Probl Pediatr Adolesc Health Care 2015 Jan;45(1):3-17.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Tavyev was recorded at the Pediatrics State of the Art Conference 2017, presented by Cedars-Sinai Medical Center and its Office of Continuing Medical Education and held June 3, 2017, in Los Angeles, CA. For information about upcoming CME conferences from Cedars-Sinai Medical Center and its Office of Continuing Medical Education, please visit www.cedars-sinai.edu/Education/Continuing-Medical-Education. The Audio Digest Foundation thanks the speakers and sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

PD634101

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.