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PAROXYSMAL DISORDERS EPILEPSY (RECURRENT SEIZURES) • A seizure is an involuntary contraction of muscle caused by abnormal electrical brain discharges. • Although about 50% of seizures are idiopathic (unknown cause), they also can be attributed to infection, trauma, or tumor growth. • Familial or polygenic inheritance may be responsible. Because they are not so much a disease as a sympto of an underlying disorder, all seizures need to be investigated. • partial seizures, only one area of the brain is involved. generalized seizures, the disturbance appears to involve the entire brain; loss of consciousness usually occurs SEIZURES IN THE NEWBORN PERIOD • consist only of twitching of the head, arms, or eyes; smacking of the lips; slight cyanosis; and perhaps respiratory difficulty or apnea. • the infant may appear limp and flaccid. ASSESSMENT • seizures in older children are often of unknown cause, 75% of seizures in neonates have a known cause such as trauma and anoxia from intrauterine life or birth; metabolic disorders, such as hypoglycemia, hypocalcemia, or lack of pyridoxine (vitamin B6); neonatal infection; or acute bilirubin encephalopathy caused by a blood incompatibility. • EEGs in the newborn may be normal despite extensive disease. • 20% of all newborns have abnormal CSF values compared with adult standards (protein is increased, and there may be a few red blood cells from rupture of subarachnoid capillaries from the pressure of birth), •lumbar puncture also is not conclusive THERAPEUTIC MANAGEMENT • High doses of antiseizure medication may be needed to control seizures in newborns because they metabolize drugs more rapidly than older children. • In adults, for example, phenobarbital may be administered in the range of 1.5 mg/kg body weight per day. In newborns, the dose might be as high as 3 to 10 mg/kg/day. SEIZURES IN THE INFANT AND TODDLER PERIOD Seizures commonly seen in this age group are infantile spasms a form of generalized seizure often called "salaam" or "jackknife" seizures, or infantile myoclonic seizures. ASSESSMENT • characterized by very rapid movements of the trunk with sudden strong contractions of most of the body, including flexion and adduction of the limbs, or the infant suddenly slumps forward from a sitting position or falls from a standing position. The episode may occur singly or in clusters as frequently as 100 times a day. • identifiable cause such as trauma, a metabolic disease such as phenylketonuria, or a viral invasion such as herpes or cytomegalovirus. • In other children, the spasms apparently result from a failure of normal organized electrical activity in the brain. • Approximately 90% of infants with this type of involvement will be developmentally delayed as intellectual development appears to halt and even regress after the pattern of seizures begins. • Most children with infantile spasms show high-amplitude slow waves and spikes, a chaotic discharge called hypsarrhythmia on an EEG tracing. • These seizures occur slightly more often in males than females THERAPEUTIC MANAGEMENT • Because the response to treatment with antiseizure therapy tends to be poor, parenteral adrenocorticotropic hormone (ACTH) therapy high-dose vigabatrin, an amino acid, are used in its place. High-dose valproate or a newer antiseizure agent such as topiramate (Topamax) may be used in children who do not respond to usual therapy, as well as pyridoxine (vitamin B6) or a ketogenic diet (see following discussion), but research shows none to be as effective as ACTH, especially for preserving neurodevelopmental outcomes • In most children, the seizure phenomenon seems to "burn itself out" by 2 years of age SEIZURES CAUSED BY POISONING OR DRUGS • The possibility of poisoning has to be considered in any child who has a first seizure. • most likely to occur between 6 months and 3 years of age it must be considered again in adolescence, when drugs may be intentionally self-administerec • Seizures also can be a late symptom of encephalopathy caused by lead poisoning SEIZURES IN CHILDREN OLDER THAN 3 YEARS OF AGE FEBRILE SEIZURES Seizures associated with high fever (102° to 104°F [38.9° to 40.0°C]) • are the most common type seen in preschool children, although these can occur as late as 7 years of age. • They are most serious if they occur under 6 • Such seizures may occur after immunization with live vaccines because these most commonly produce fevers.The seizure only lasts 1 to 2 minutes or less. • Further evaluation is necessary after a febrile seizure to exclude underlying conditions or infections PREVENTION • Teach parents that every child who has a febrile seizure must be seen by a healthcare provider to rule out meningitis and to be aware that it will be assumed by emergency room personnel that the child has meningitis until it is ruled out by a complete neurologic workup. collipiere neurologic workup THERAPEUTIC MANAGEMENT • parents should sponge the child with tepid water to reduce the fever quickly. • Advise them not to put the child in a bathtub of water to do this because it would be easy for the child to slip under water should a second seizure occur. • Caution parents not to apply alcohol or cold water because extreme cooling causes shock to an immature nervous system; in addition, alcohol can be absorbed by the skin or the fumes can be inhaled in toxic amounts, compounding the child's problems. • Parents should not attempt to give oral medications such as acetaminophen because the child will be in a drowsy, or postictal, state after the seizure and might aspirate the medicine. • Suppositories may be given at the appropriate dose. • If attempts to reduce the child's temperature by sponging are unsuccessful, advise parents to put cool washcloths on the child's forehead, axillary, and groin areas and transport the child, lightly clothed, to a healthcare facility for immediate evaluation. • At the healthcare facility, a lumbar puncture will be performed to rule out meningitis. • If warranted, antipyretic drugs to reduce the fever below seizure levels will be administered. • Appropriate antibiotic therapy will be prescribed if an infection is documented • Many parents need to be reassured that febrile seizures do not lead to brain damage and that the child is almost always completely well afterward. COMPLEX PARTIAL (PSYCHOMOTOR OR TEMPERAL LOBE) SEIZURES • organic causes such as laceration of brain tissue from an automobile accident or fall, an enlarging brain tumor, hemorrhage due to a blood dyscrasia, infection (meningitis or encephalitis), anoxia, or toxic conditions such as lead poisoning that have left residual damage. • The possibility that brain trauma could have been caused by child maltreatment is always another possibility to consider. Complex partial (psychomotor) seizures vary greatly in extent and symptoms and tend to be a difficult type to control. • The child may notice a slight aura, or sensation a seizure is about to occur, but this is rarely as definite as that seen with tonic-clonic seizures. • Results of a CT or MRI scan and EEG will invariably be normal. • begins with a sudden change in posture, such as an arm dropping suddenly to the side. • Other motor, sensory, and behavioral signs might include automatisms (complex purposeless movements, such as lip smacking, fumbling hand movements, intense running, or screaming). • A few children may then slump to the ground, unconscious. Circumoral pallor develops due to a halt in respirations. • The child begins breathing again almost immediately and usually regains consciousness in less than 5 minutes. He or she may feel slightly drowsy afterward but does not have an actual postictal stage or a period of sustained unconsciousness as seen with tonic-clonic seizures. THERAPEUTIC MANAGEMENT Common drugs used to treat this type of seizure include carbamazepine (Tegretol) or valproate (Depakene). Carbamazepine can lead to neutropenia, so white blood cell counts need to be monitored during therapy. • If these drugs are not effective, surgery to remove the epileptogenic focus or the implantation of a vagus nerve stimulator can be used to significantly reduce seizure frequency. If seizures cannot be controlled fully, parents need to anticipate potentially hazardous situations during their child's day, such as having to cross a busy street on the way to school or riding a bicycle are not eligible to drive until they are cleared by their primary care provider (after about a year free of seizures) PARTIAL (FOCAL) SEIZURE : A typical ratal sezue bran morer signs begins in • If the movement remains localized, there will be no loss of consciousness. • If the spread is extensive, the seizure can cross the midline and become generalized and, at that point, is impossible to differentiate from a full generalized tonic-clonic seizure. • This makes it important, therefore, to observe children carefully as a seizure begins to distinguish whether it began with local signs such as numbness, tingling, paresthesia, or pain all associated with one brain area. Documenting the spread can help localize the spot in the brain that first initiated the abnormal electrical discharge or be instrumental in detecting the location of a rapidly growing brain tumor