Pediatric Seizures - As per OP Ghai (Essential Pediatrics)

Note: OP Ghai's Essential Pediatrics is not in the textbook library. The content below is synthesized from authoritative pediatric references (Harriet Lane Handbook, Tintinalli's Emergency Medicine, Rosen's Emergency Medicine, Bradley & Daroff's Neurology) and reflects the standard classification, clinical content, and approach covered in OP Ghai's seizure chapter.

Definition

Classification of Seizures (ILAE 2017)

1. Focal (Partial) Seizures

• Focal aware (simple partial): consciousness preserved; motor, sensory, autonomic, or psychic features
• Focal impaired awareness (complex partial): consciousness impaired; automatisms common
• Focal to bilateral tonic-clonic: secondary generalization

2. Generalized Seizures

3. Unknown Onset Seizures

• Epileptic spasms (infantile spasms)

Causes of Seizures by Age

Febrile Seizures (Most Important Pediatric Topic)

Definition

• Incidence: 2-5% of children
• Most common seizure disorder in children

Types

Management of Simple Febrile Seizure

• No routine blood tests, EEG, neuroimaging required in a well-appearing, fully immunized child with normal neurology and no meningeal signs
• Identify and treat the source of fever
• LP should be strongly considered if signs of meningitis; also consider in infants 6-12 months who are unimmunized for Hib or S. pneumoniae
• Antipyretics given for fever, but antipyretics do not prevent recurrence
• Anticonvulsants NOT recommended for simple febrile seizures (side effects outweigh minor recurrence risk)

Recurrence Risk

• Children <12 months at first episode: ~50% will recur
• Children >12 months: ~30% will recur
• Risk factors for recurrence:
  • Family history of febrile seizures
  • Age <12 months at first seizure
  • Low fever at time of first seizure
  • Short interval between fever onset and seizure

Risk of Developing Epilepsy

• After simple febrile seizure: ~1% (same as general population)
• After complex febrile seizure or family history of epilepsy: up to 7%

Specific Pediatric Epilepsy Syndromes

1. West Syndrome (Infantile Spasms)

• Age: 3-12 months (peak 4-6 months)
• Triad: Infantile spasms + hypsarrhythmia on EEG + developmental regression
• Spasms: Sudden brief flexion ("salaam attacks") - neck + trunk flexion, arms abduct
• EEG: Hypsarrhythmia (chaotic high-amplitude disorganized pattern)
• Causes: Tuberous sclerosis (most common identifiable), Down syndrome, perinatal HIE, structural malformations; 30% cryptogenic
• Treatment: ACTH (first-line), vigabatrin (especially in tuberous sclerosis), prednisolone
• Prognosis: Poor - most develop intellectual disability and other seizure types

2. Lennox-Gastaut Syndrome

• Age: 1-8 years (peaks 3-5 years)
• Triad: Multiple seizure types (tonic, atonic, atypical absence) + slow spike-wave on EEG (<2.5 Hz) + intellectual disability
• EEG: Slow (1.5-2.5 Hz) spike-wave discharges
• Treatment: Valproate (drug of choice), lamotrigine, rufinamide, clobazam, felbamate, cannabi-diol; ketogenic diet; VNS
• Prognosis: Poor

3. Childhood Absence Epilepsy (Pyknolepsy)

• Age: 4-12 years (peak 5-7 years); girls > boys
• Seizures: Multiple brief absence episodes daily (up to 100/day), abrupt onset and offset, no postictal phase
• EEG: 3 Hz generalized spike-and-wave discharges; hyperventilation triggers
• Treatment: Ethosuximide (drug of choice), valproate, lamotrigine
• Prognosis: Good - ~80% remit by adolescence

4. Juvenile Myoclonic Epilepsy (JME)

• Age: 12-18 years
• Triad: Myoclonic jerks (on awakening) + generalized tonic-clonic seizures + absence seizures
• Triggers: Sleep deprivation, alcohol
• EEG: 4-6 Hz polyspike-and-wave
• Treatment: Valproate (drug of choice), levetiracetam, lamotrigine
• Prognosis: Good seizure control but usually lifelong medication needed

5. Benign Rolandic Epilepsy (BCECTS)

• Age: 3-13 years; boys > girls
• Seizures: Focal, hemifacial twitching, hypersalivation, grunting; often nocturnal; no LOC
• EEG: Centrotemporal (rolandic) spikes
• Treatment: Often no treatment needed; carbamazepine if required
• Prognosis: Excellent - all remit by 16 years

Status Epilepticus

Definition

• Seizure lasting >30 minutes OR
• Two or more seizures without full recovery of consciousness between them

Management (Step-wise Protocol)

• ABC, oxygen, IV access, blood glucose (treat if <60 mg/dL with 2 mL/kg of 10% dextrose)
• Check glucose, electrolytes, calcium, CBC, toxicology

• Lorazepam IV: 0.1 mg/kg IV (max 4 mg) - preferred
• Diazepam IV: 0.2-0.5 mg/kg IV (child <5 yr: max 5 mg; child ≥5 yr: max 10 mg)
• Diazepam rectal: 0.5 mg/kg if no IV access
• Midazolam IM/intranasal: 0.2 mg/kg (max 10 mg) - if no IV access

• Phenobarbital additional doses
• Valproate IV

• Midazolam infusion: 0.05-0.4 mg/kg/h
• Propofol IV: 1.5-4 mg/kg/h
• Pentobarbital coma: 0.5-5 mg/kg/h
• Ketamine IV infusion

Neonatal Seizures

Types (Clinical Classification)

Causes

• HIE (hypoxic-ischemic encephalopathy) - most common
• Intracranial hemorrhage
• Metabolic: hypoglycemia (most treatable), hypocalcemia, hyponatremia, hypomagnesemia
• Infections: meningitis, encephalitis
• Pyridoxine deficiency (give pyridoxine 100 mg IV if refractory)
• Drug withdrawal (neonatal abstinence syndrome)
• Inborn errors of metabolism

Management

1. Treat underlying cause first (correct glucose, calcium, magnesium)
2. Phenobarbital - drug of choice for neonatal seizures: 20 mg/kg IV
3. Phenytoin: 20 mg/kg IV (second-line)
4. Pyridoxine (B6) 100 mg IV - if refractory/unexplained

Key Anticonvulsant Drugs in Pediatrics

Electroencephalogram (EEG) Patterns

Key High-Yield Points for Exams

1. Most common seizure in children = Febrile seizure
2. Most common cause of status epilepticus in children = Febrile seizure (prolonged)
3. Drug of choice for absence seizures = Ethosuximide (pure absence) / Valproate (absence + other types)
4. Drug of choice for infantile spasms = ACTH / Vigabatrin (in tuberous sclerosis)
5. Drug of choice for neonatal seizures = Phenobarbital
6. Drug of choice for status epilepticus = Lorazepam (first-line benzodiazepine)
7. EEG in West syndrome = Hypsarrhythmia
8. Salaam attacks = Infantile spasms / West syndrome
9. Petit mal = Absence seizures; Grand mal = GTCS
10. Simple febrile seizure does NOT increase epilepsy risk; complex does (up to 7%)
11. Rolandic epilepsy = Best prognosis; always remits
12. JME = Valproate; requires lifelong treatment despite good seizure control
13. Febrile seizure recurrence risk: 50% if first seizure <12 months; 30% if >12 months
14. Todd's paralysis = transient postictal focal weakness after focal/GTCS seizure
15. Antipyretics do NOT prevent febrile seizure recurrence