Seizures, convulsions or fits are non-specific terms describing any impairment of consciousness, abnormal motor activity, sensory disturbance or autonomic dysfunction. Epilepsy is a specific diagnosis defined as a condition where fits are recurrent, resulting from paroxysmal involuntary disturbances of brain function that are unrelated to fever or acute cerebral insult. Seizures may be generalized from the onset, or focal, when they begin in a localized or focal area of the brain. Focal fits can be motor, sensory or autonomic, or a mixture of these three, and can become generalized. Epilepsy is usually idiopathic, but may result from a cerebral insult or underlying anatomical lesion, when it is called secondary. In some children, an insult or neurological problem is suspected but cannot be found and this type of epilepsy is cryptogenic.
The diagnosis of epilepsy is clinical, the key being a good detailed history. Physical examination is usually normal, but the finding of neurological signs suggests an underlying pathology. Investigations are not usually helpful as 50% of children with epilepsy have normal EEGs on first testing, and 5% of normal children have abnormal EEGs. EEG is useful in diagnosing certain syndromes, e.g. childhood absence epilepsy (previously called petit mal) and West’s syndrome (infantile spasms). Twenty-four hour and video EEG recordings are sometimes helpful. MRI is usually indicated in children with focal epilepsy, and CT scans in acute neurological insults.
Medical Management of Epilepsy
The goal is to achieve the greatest control of fits while producing the least degree of side-effects. This is best achieved through a monotherapy approach:
- Treatment is started with the most effective drug for the type of fit.
- The dose is gradually increased to maximum recommended levels.
- A second drug is added if the first is ineffective, and the dose increased.
- The first drug, where possible, is gradually discontinued.
- Drugs should be given at intervals no longer than one half-life. Drugs with sedative effects should be given at bedtime and, if there is a pattern, the peak level should be timed to coincide with the seizures.
Most children are started on sodium valproate or carbamazepine, except for those with infantile spasms when steroid or vigabatrin (if associated with tuberous sclerosis) is the first line treatment. Ethosuxamide is an alternative to valproate for children with absence seizures only. If medical treatment fails, surgery may rarely be tried in children with intractable fits and clinical and electrographic evidence of a discrete epileptic focus. For most children with epilepsy restriction of physical activity is unnecessary, other than attendance by a responsible adult while bathing and swimming. As with any child, a helmet is recommended when cycling. Avoiding cycling in traffic and climbing high gymnastic equipment is prudent.
It is recommended that newly diagnosed children should receive support from an epilepsy nurse. The National Society for Epilepsy is a good source of information and support for the children and families.
Management of a Tonic–Clonic Seizure
In a tonic–clonic seizure, the child should be placed in the recovery position after the fit is over. If the fit lasts for more than 10 minutes, parents should be instructed to end it by giving buccal midazolam or rectal diazepam. Intravenous drugs should only be given in hospital where facilities are available in the event of respiratory arrest. Children do not need to be hospitalized each time a fit occurs. Emergency treatment is not required for other forms of epileptic fits.
Monitoring a Child with Epilepsy
The family should be encouraged to keep a diary recording any fits along with medications received, side-effects and behavioural changes. This allows you to accurately review the child’s condition and the effect of drugs. Physical examination is not required at every visit but should be carried out if there is a deterioration in control. Monitoring of anticonvulsant blood levels is not routine but is helpful if fits are uncontrolled or drug toxicity is suspected. Levels below the therapeutic range can result from inadequate dosage, poor absorption, rapid drug metabolism, drug interactions and deliberate or accidental non-compliance.
Living with Epilepsy
Epilepsy is a difficult condition for children to live with as it periodically and unpredictably places them in embarrassing situations. They may suffer from stigmatization and social difficulties, and their integration into school may become affected. Too often physical activities are limited for fear that a fit will place the child in danger.
Most parents are initially frightened by the diagnosis of epilepsy and require support and accurate information about the condition. They need to know how to safely manage an acute fit including using buccal midazolam or rectal diazepam, about side effects of drugs, the dangers of sudden withdrawal of medication, and social and academic repercussions. There may be concern about genetic implications, and it is important that teenage girls know about the teratogenic effects of anticonvulsants.
Families may need to be encouraged to treat their child as normally as possible and not to thwart their independence. This often becomes a particular issue in adolescence when compliance too can be a problem. Career guidance is important as some occupations are closed to individuals with epilepsy. Application for a driving licence can only be made after one fit-free year whether the person is on or off medication.
Staff at school must be taught the correct management of tonic–clonic seizures. Teachers need to be aware of other types of fit such as absence seizures, as well as side-effects of drugs, and report these to the parents or school nurse. When epilepsy is associated with learning difficulties, appropriate help needs to be provided.
- Ensure the diagnosis is correct.
- Only treat if fits are recurrent.
- Use monotherapy when possible.
- Check plasma levels if control is inadequate and, if low, consider non-compliance.
- For tonic–clonic epilepsy, buccal midazolam or rectal diazepam should be prescribed for home use.
- Ensure any learning difficulties are addressed.
- Help the child live a normal life with full participation at school and home.