Seizures and Epilepsy in Children
Epilepsy is a neurological condition involving the brain that makes people more susceptible to having recurrent unprovoked seizures. It is one of the most common disorders of the nervous system and affects people of all ages, races and ethnic background. According to the Epilepsy Foundation of America, nearly 3 million Americans live with epilepsy.
Anything that interrupts the normal connections between nerve cells in the brain can cause a seizure. This includes a high fever, low blood sugar, alcohol or drug withdrawal, or a brain injury. Under these circumstances, anyone can have 1 or more seizures. However, when a person has 2 or more recurrent unprovoked seizures, he or she is considered to have epilepsy. Epilepsy may have a genetic, structural/metabolic, or unknown cause. Some examples include tumors, strokes, brain damage from illness or injury, or some combination of these.
Electroclinical syndromes are specific types of epilepsy that share clinical features, seizure types, and EEG patterns. These syndromes are believed to have a genetic cause, though in most cases the exact genetic change is unknown. Some examples of electroclincial syndromes include Childhood Absence Epilepsy, Benign Rolandic Epilepsy, and Juvenile Myoclonic Epilepsy.
What is a seizure?
The brain is the center that controls and regulates all voluntary and involuntary responses in the body. It consists of nerve cells that normally communicate with each other through electrical activity.
A seizure occurs when part(s) of the brain receives a burst of abnormal electrical signals that temporarily interrupts normal electrical brain function.
What are the different types of seizures?
The type of seizure depends on which part and how much of the brain is affected and what happens during the seizure. The 2 broad categories of epileptic seizures are focal seizures (with and without dyscognitive features) and generalized seizures. Focal seizures result from abnormal activity in one hemisphere of the brain and generalized seizures result from abnormal activity from both hemispheres. The words we use to describe focal and generalized seizures have changed over the years.
- Focal seizures. Focal seizures may also be called partial seizures and results from abnormal electrical activity in one side of the brain. With some focal seizures your child may experience an aura before the seizure occurs. The most common auras may be a feeling of deja vu, impending doom, fear, or euphoria. Visual changes, hearing abnormalities, or changes in the sense of smell can also be auras. Two types of focal seizures include:
- Focal seizures without dyscognitive features (these are also called "simple partial seizures"): Your child may show different symptoms depending upon which area of the brain is involved. If the abnormal electrical brain activity occurs in the occipital lobe (the back part of the brain that is involved with vision), the child's sight may be altered. If the abnormal activity occurs in the frontal lobe, a child's muscles are affected. The seizure may be limited to an isolated muscle group, such as fingers, or to larger muscles in the arms and legs. Children may also experience sweating, nausea, or may be come pale. Consciousness is not lost in this type of seizure and your child may remember what he experienced during this seizure type.
- Focal seizures with dyscognitive features (these are also called "complex partial seizures"): This type of seizure commonly occurs in the temporal lobe of the brain, the area of the brain that controls emotion and memory function. This seizure usually lasts 1 to 2 minutes. Consciousness is usually lost during these seizures. Losing consciousness may not mean that your child passes out. Rather, he or she may just stop being aware of his or her surroundings. Your child may look awake but have a variety of abnormal behaviors. These behaviors may range from gagging, lip smacking, running, screaming, crying, and/or laughing. Children do not remember what they experience during this seizure type. When your child regains consciousness, he may appear confused or disoriented and complain of being tired or sleepy after the seizure. This is called the postictal period.
- Generalized seizures. Generalized seizures result from abnormal electrical activity in both sides of the brain. There is loss of consciousness and usually a postictal (after the seizure) state after the seizure occurs. Types of generalized seizures include the following:
- Absence seizures (in the past, these were called "petit mal seizures"): These seizures are characterized by brief episodes of behavioral arrest, loss of awareness, and staring. Typically, posture is maintained during the seizure and falls do not occur. The mouth or face may move or the eyes may blink. These seizures are usually brief and last no longer than 30 seconds. When the seizure is over, your child may not recall what just occurred. He or she may continue with his or her activities as though nothing happened. There is not a postictal period with this seizure type. Absence seizures usually start between ages 4 to 12 years and may occur many times a day. This type of seizure is sometimes mistaken for a learning problem or behavioral problem.
- Atonic seizures (also called "drop attacks" or "drop seizures"): With atonic seizures, there is a sudden loss of muscle tone. Your child may fall from a standing position or suddenly drop his or her head. During the seizure, your child remains limp and unresponsive. These seizures typically last only moments in duration.
- Generalized tonic-clonic seizures (In the past, these were called "grand mal seizures"): The classic form of this kind of seizure, which may not occur in every case, is characterized by 5 distinct phases. The body, arms, and legs will flex (contract), extend (straighten out), tremor (shake), have a clonic period (jerking with contraction and relaxation of the muscles), followed by a postictal period. Not all of these phases may be seen with every one of this type of seizure. Urinary incontinence and biting of the tongue or inside of the cheek may occur. During the postictal period, your child may be sleepy, have problems with vision or speech, may have a bad headache, vomiting, fatigue, or may have body aches.
- Myoclonic seizures: Myoclonic seizures may appear as sudden, quick jerks in a group of muscles in your child's arms, legs or both. These seizures tend to occur in clusters, meaning that they may occur several times a day, or for several days in a row. They most commonly occur as children are awaking from sleep or shortly after being up for the day.
- Infantile Spasms (also called West Syndrome): This is a rare, severe type of epilepsy in infants and occurs with loss of developmental milestones. Spasms may appear as clusters of sudden body, arm, or leg extension (straightening), flexion (bending), or stiffening. These may occur more frequently after awakening from sleep. Infants may have hundreds of these seizures a day. This can be a serious problem and can have long-term complications. If still present after the age of 2 years, these seizures are called epileptic spasms.
- Febrile seizures: Febrile seizures are relatively common in the general population. This type of seizure is associated with a fever and is not epilepsy, although a fever may trigger a seizure in a child who has epilepsy. These seizures occur in children between 6 months and 5 years of age. There may be a family history of febrile seizures. Febrile seizures may be simple (generalized, last less than 15 minutes, and do not recur in a 24-hour period) or complex (focal, last longer than 15 minutes, or recur more than once in a 24-hour period). A febrile seizure or series of seizures lasting longer than 30 minutes without return to baseline is called febrile status epilepticus. Simple febrile seizures typically do not have long-term neurological effects and most children who have more than one simple febrile seizure in their life do not develop epilepsy. Complex febrile seizures or febrile status epilepticus may result in long-term neurological changes and many of these children will develop epilepsy.
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Causes & Risk Factors
A child may experience one or many different types of seizures. While the exact cause of the seizure may not be known, the more common seizures are caused by the following:
- In newborns and infants:
- Birth trauma
- Congenital (present at birth) problems
- Metabolic or chemical imbalances in the body
- In children, adolescents, and young adults:
- Alcohol or drugs
- Trauma to the head or brain injury
- Congenital conditions
- Genetic factors
- Unknown reasons
- Other possible causes of seizures may include:
- Brain tumor
- Neurological problems
- Drug withdrawal
- Use of illicit drugs
Symptoms & Types
A child may have different or varying degrees of symptoms depending on the type of seizure. The following are general symptoms of a seizure or warning signs that your child may be experiencing seizures. Symptoms or warning signs may include:
- Jerking movements of the arms and legs
- Stiffening of the body
- Loss of consciousness
- Breathing problems or breathing stops
- Loss of bowel or bladder control
- Falling suddenly for no apparent reason, especially when associated with loss of consciousness
- Not responding to noise or words for brief periods
- Appearing confused or in a haze
- Nodding the head rhythmically, when associated with loss of awareness or even loss of consciousness
- Periods of rapid eye blinking and staring
During the seizure, the child's lips may become bluish and breathing may not be normal. The movements are often followed by a period of sleep or disorientation.
The symptoms of a seizure may resemble other problems or medical conditions. Always consult your child's doctor for a diagnosis.
Diagnosis & Tests
The full extent or cause of the seizure may not be completely understood immediately after onset of symptoms, but may be revealed with a comprehensive medical evaluation and diagnostic testing. The diagnosis of a seizure is made with a physical examination and diagnostic tests. During the examination, the doctor will obtain a complete medical history and will ask many questions about when the seizure occurred. Seizures may be due to neurological problems and require further medical follow up.
Diagnostic tests may include:
- Blood tests
- Electroencephalogram (EEG). A procedure that records the brain's continuous, electrical activity by means of electrodes attached to the scalp.
- Magnetic resonance imaging (MRI). A diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body.
- Computed tomography scan (also called a CT or CAT scan). A diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce horizontal, or axial, images (often called slices) of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general X-rays.
- Lumbar puncture (spinal tap). A special needle is placed into the lower back, into the spinal canal. This is the area around the spinal cord. The pressure in the spinal canal and brain can then be measured. A small amount of cerebral spinal fluid (CSF) can be removed and sent for testing to determine if there is an infection or other problems. CSF is the fluid that bathes your child's brain and spinal cord.
Treatment & Care
Specific treatment for a seizure will be determined by your child's doctor based on:
- Your child's age, overall health, and medical history
- Extent of the condition
- Type of seizure
- Your child's tolerance for specific medications, procedures, or therapies
- Expectations for the course of the condition
- Your opinion or preference
The goal of seizure management is to control, stop, or decrease the frequency of the seizures without interfering with the child's normal growth and development. The major goals of seizure management include the following:
- Proper identification of the type of seizure
- Proper identification of the type of epilepsy
- Using medication specific to the type of epilepsy
- Using the least amount of medication to achieve adequate control
- Maintaining good medication levels
Treatment may include:
- Medications. There are many types of medications used to treat epilepsy. Medications are selected based on the type of epilepsy, age of your child, side effects, cost of medication, and the adherence with the use of the medication.
Medications used at home are usually taken by mouth (as capsules, tablets, sprinkles, or syrup), but some can be given rectally (into the child's rectum). If the child is in the hospital with seizures, medication by injection or intravenous (IV) may be used.
It is important to give your child his or her medication on time and as prescribed by your child's doctor. Different people use up the medication in their body differently, so adjustments (schedule and dosage) may need to be made for good control of seizures.
All medications can have side effects, although some children may not experience side effects. Discuss your child's medication side effects with his or her doctor.
While your child is taking medications, different tests may be done to monitor the effectiveness of the medication. These tests may include the following:
- Blood work. Frequent blood draws testing may be needed to check the level of the medication in the body. Based on this level, the doctor may increase or decrease the dose of the medication to achieve the desired level. This level is called the therapeutic level and is where the medication works most efficiently. Blood work may also be done to monitor the effects of medications on body organs such as the liver or kidneys.
- Urine tests. These tests may be performed to see how the child's body is responding to the medication. Urine tests are not usually needed for medications but may be required for certain therapies such as the ketogenic diet (discussed below).
- Electroencephalogram (EEG). A procedure that records the brain's continuous, electrical activity by means of electrodes attached to the scalp. This test may be repeated to monitor how the medication is helping.
- Epilepsy Surgery. Children with epilepsy and seizures that do not respond to at least 2 seizure medications have "medically intractable" (also called "medically refractory" or "treatment resistant") epilepsy. These children's seizures are less likely to respond to other medications but may respond to epilepsy surgery. In some cases, epilepsy surgery can cure seizures, and in other cases, surgery may help the intensity or frequency of seizures (this is known as "palliative" surgery). Surgery may be considered in a child who:
- Has seizures that are unable to be controlled with medications
- Has seizures that always start in one area of the brain
- Has a seizure in a part of the brain that can be removed without disrupting important behaviors such as speech, memory, or vision
All children who may be surgical candidates must undergo a careful pre-surgical evaluation at a specialized epilepsy center. This evaluation will include a hospital stay to capture all seizure types on scalp EEG, pictures of your child's brain to look at brain function and structure, and a neuropsychological evaluation to measure how your child uses language, memory and solves problems. Following this evaluation, your child's findings will be carefully discussed in a multi-specialist epilepsy surgery conference. A surgery may be recommended based on your child's individual case.
Epilepsy surgery for seizures is performed by a specialized surgical team. The operation may remove the part of the brain where the seizures are occurring, or may help to stop the spread of the abnormal electrical activity through the brain. Surgery may involve opening the skull to operate directly on the brain or may involve the use of a laser catheter through a small drill hole.
Depending on the type of epilepsy and surgery recommended, your child may be awake during the surgery. The brain itself does not feel pain. With your child awake and able to follow commands, the surgeons are better able to make sure that important areas of the brain are not damaged.
Surgery is not an option for everyone with seizures. Discuss this with your child's doctor for more information.
- Ketogenic Diet. Certain children whose seizures are not well-controlled, or who have problems with medications, may be placed on a special diet called the ketogenic diet. Some children with a special condition called Glucose Transporter Type 1 Deficiency syndrome always require the Ketogenic diet to treat their seizures. This type of diet is relatively low in carbohydrate and relatively high in fat and protein.
What is the ketogenic diet?
The Ketogenic diet may be a treatment option for children whose seizures are not controlled with medication. This treatment was developed more than 80 years ago, but no one knows exactly how the diet works. Some children (up to 1/3) become seizure-free when put on the diet. However, the diet does not work for everyone. About 30% of children who try the diet may not experience any changes in their seizures. Ask your child's neurologist if you are interested in this diet. The doctor can determine if this diet is right for your child.
What does the ketogenic diet consist of?
The Ketogenic diet is very high in fat (about 90% of the calories come from fat). Protein is given in normal amounts to help promote growth. A very small amount of carbohydrate is included in the diet. While on the diet, the body thinks that it is starving. This very high-fat, low-carbohydrate diet causes the body to use fat instead of carbohydrates for energy and this generates a special type of chemical called ketones. The breakdown of fat and presence of ketones is important to the success of the diet and can help reduce seizures.
The Ketogenic diet does not allow any milk, whole grain breads and cereals, and has limited fruits and vegetables. The ketogenic diet is not nutritionally balanced, therefore, vitamin and mineral supplements are needed.
How is the ketogenic diet started?
Your child will have an Electrocardiagram (EKG) and blood drawn before starting the diet. When the ketogenic diet is started, your child will be admitted to the hospital. It may take 4 to 5 days in the hospital to get the diet started and for you to learn how to plan the diet. Children on this diet must be carefully monitored by medical team familiar with the ketogenic diet, including a dietician. This diet is very strict and requires a family commitment. It is important not to start the diet on your own because, like other therapies for epilepsy, it is a serious treatment with side effects that need to be carefully watched for.
During the hospital admission to start the diet, you may be taught how to check your child's urine for ketones. The dietitian will help determine how much fat, protein, and carbohydrate your child is allowed to have, usually divided into three meals a day. The ketogenic diet can by very challenging to prepare and requires that all foods be weighed using a food scale.
Some medications and other products, such as toothpaste and mouthwash, contain carbohydrates. It is important to only use products approved by the ketogenic diet team. Your child may not make ketones in their urine if too many carbohydrates are included in the diet. Your child's doctor and dietitian will give you a list of medications, and other products, that are free of carbohydrates.
How long is the ketogenic diet used?
Doctors often ask parents to try the diet for at least 1 month, and even as long as 2 or 3 months, if it is not working at first. Your child may continue to take anti-seizure medicines but may be able to take less in the future. Most children usually stay on the diet about 2 years but some may require a longer period of time. The diet is then slowly changed back to a regular diet.
Are there any side effects of the Ketogenic diet?
Long term side effects include dehydration, constipation, and sometimes complications from kidney stones or gall stones. Short term side effects include a decrease in blood sugar, vomiting, and feeling tired. This is why the diet requires a hospital admission when first started and requires regular blood draws while on the diet.
- Vagus Nerve Stimulation (VNS). Some children with uncontrolled seizures on seizure medications may benefit from a procedure called Vagus Nerve Stimulation (VNS). VNS may be considered for children of any age with seizures that are not controlled by medications and whose seizures cannot by cured by epilepsy surgery.
VNS attempts to control seizures by sending small pulses of electrical energy to the brain from the vagus nerve, which is a large nerve in the neck. This is done by surgically placing a small battery under the skin, usually in the left upper chest wall. Small wires are then attached to the battery and placed under the skin and around the vagus nerve. The battery is then programmed to send energy impulses to the brain.
If your child has a VNS and feels a seizure coming on, he or she may activate the impulses by briefly holding or passing a small magnet over the battery. In many people, this will help to stop the seizure. VNS has also been shown to improve mood in adults with epilepsy. There are some side of the effects that may occur with the use of VNS. These may include, but are not limited to, the following:
- Pain or discomfort in the throat
- Change in voice
More information regarding the child with seizures or epilepsy
- Make sure you and your child (if age appropriate) understand the type of seizure that is occurring and the type of medication(s) that are needed.
- Know the dose, time, and side effects of all medications.
- Consult your child's doctor before giving your child other medications. Medications for seizures can interact with many other medications, causing the medications to work improperly and/or causing side effects.
- Young women of childbearing age, who are on seizure medications, should be informed that some seizure medications are harmful to a fetus, and some medications may decrease the effectiveness of oral contraceptives.
- Check with your state to understand the laws about people with epilepsy or seizures operating a motor vehicle.
- Even if your child's seizures are under full control, standard seizure precautions should be used. These are minimal restrictions his or her activities. Your child should always wear a helmet with sports and bike riding (including in-line roller-skating, hockey, and skateboards). He or she should not climb above 4 feet high. Your child should also always have 1:1 adult supervision while swimming.
- Specific follow-up will be determined by your child's doctor.
- Medications for seizures may not be needed for your child's entire life. Some children may be taken off their medications if they have been seizure-free for 1 to 2 years. This will be determined by your child's doctor.