Seizures and epilepsy in children

There are many types of seizures, and not all of them are “falling and shaking”:

• Generalized tonic-clonic: consciousness is lost, the body stiffens and then jerks rhythmically; the lips may turn blue; deep sleep follows.
• Absence: the child “zones out” for 5–15 seconds, eyes staring blankly, no response when called, and then carries on as if nothing happened. It can repeat dozens of times a day and is often mistaken for “inattention.”
• Focal: shaking of one part of the body (a hand, the face), strange sensations, fear, automatic movements (chewing, rubbing the hands); awareness may be partly kept or lost.
• Myoclonic: sudden, brief jerks, often right after waking up.
• Seizures during sleep: waking at night, twitching of the facial muscles, foaming at the mouth. Some childhood epilepsies appear only during sleep.

Many events in children look like seizures but are not epilepsy: in babies, benign sleep myoclonus and shuddering attacks; breath-holding spells when crying; fainting, night terrors, tics, and daydreaming. In some of these the EEG is normal and no treatment is needed. The difference is established by the exam, a description of the episode and, when indicated, video-EEG.

According to the international practice standard, an EEG is a standard part of the evaluation in a child with a first seizure without fever. Lab tests and imaging (MRI) are done only when clinically indicated: focal signs, abnormal findings on exam, developmental delay, or a child younger than 1 year. The main part of the evaluation is the conversation: what happened before the seizure, how long it lasted, how the child was afterward, whether there was lack of sleep or fever, and whether anyone in the family has epilepsy.

The ILAE classification has three levels: the seizure type (focal, generalized, unknown onset), the epilepsy type, and, where possible, the epilepsy syndrome (for example, childhood absence epilepsy, self-limited centrotemporal spike epilepsy, juvenile myoclonic epilepsy). Once the syndrome is identified, the outlook and the choice of medicine become more precise. Causes can be genetic, structural (birth injury, a developmental malformation), metabolic, infectious or immune; in many children no cause is found, and that does not mean the outlook is poor.

When medication is started

Usually after the second unprovoked seizure, or after a first seizure when the risk of recurrence is high. The medicine is chosen according to the seizure type, age, sex and other conditions; treatment starts with one medicine and the dose is raised gradually. In most children, seizures come under control with one or two medicines.

Monitoring

A seizure diary, watching for side effects, blood tests when needed, and follow-up EEGs. A regular sleep schedule, taking the medicine on time, and avoiding triggers (lack of sleep, and in some children flashing lights) are part of the treatment.

Stopping medication

After a long seizure-free period (usually 2 years), a gradual reduction of the medicine is discussed, taking the EEG and the syndrome into account. According to the ILAE definition, epilepsy is considered “resolved” in age-dependent syndromes once the child has passed that age, or after 10 years without seizures with the last 5 years off medication.

During a seizure: lay the child on their side, make the surroundings safe, put something soft under the head, put nothing in the mouth, do not hold the movements down, note the time, and film it if you can. If the child falls asleep after the seizure, keep them on their side and watch them.