Pediatric Epilepsy: A New Algorithm for Providers, Plus Save the Date for our Epilepsy Symposium This Fall

Evaluation and Management of a Child with Suspected Seizure 

Epilepsy is the most common neurological disorder in children, but a child’s first contact with the medical system after a suspected seizure is almost always through the emergency room or their primary care provider, not directly with a pediatric neurologist. Therefore non-neurologists are the first line of evaluation, care and often long-term management in areas without immediate access to a neurologist. Thoughtful evaluation of a suspected seizure patient, whether they are presenting with a first suspected seizure or are a known epilepsy patient who is new to a primary care practice, allows these children to receive the correct level of care and helps worried families to know what to expect next.

• See our new Epilepsy/seizure algorithm.

History

Just as with any other medical condition, the history and physical examination are the first step.

Common suspected seizure types include “convulsions” and “staring spells.” The terms “grand mal” and “petit mal” are old-fashioned and only indicate whether the onlooker saw a convulsive or nonconvulsive event; they do not indicate whether the event was epileptic, or even what type of seizure was witnessed if it was in fact an epileptic seizure.

Seizures can broadly be categorized as “focal” or “generalized”; this reflects whether the seizure is known or suspected to come from a single region of the brain or a more broadly distributed network involving most of the brain. Both types of seizures can present as a convulsion or staring spell. An additional category of event that should be considered is the nonepileptic event, which includes other neurological phenomena such as movement disorders or stereotypies, other medical phenomena such as syncope or a pulmonary event, or a behavioral event including psychogenic nonepileptic seizures. (Detailed descriptions of different seizure types are available at EpilepsyDiagnosis.org.)

The provider should attempt to interview the child if possible, as well as the family and/or witnesses. Cell phone videos can be helpful as well. In addition to a description of the event from beginning to end, the child may be able to describe a premonitory sensation or “aura” prior to the event and can describe if they had any awareness during the event. In nonverbal or very young children, altered behavior or seeking parental comfort prior to the event may indicate an aura. Other valuable details include the time of day, activity at the time of the event, general state of health and other suspected triggering factors such as fatigue, a provoking event or emotional state. Injury such as a lateral tongue bite or other injuries from a fall should be asked about, as well as whether there was any incontinence. The provider should also ask how the child felt or behaved immediately after the event, including fatigue, ability to move and speak normally and when they were back to baseline.

Staring Spells

Convulsive Events

Infantile Spasms

Infantile spasms are a unique seizure type in infants that has a high risk of serious neurodevelopmental consequences (ongoing seizures, cognitive disability and developmental regression), particularly if not treated promptly with the correct medications. The onset is generally between 6 and 12 months of age but can appear earlier or later in rare cases. These seizures present as clusters of stereotyped brief jerks of limbs when waking up or falling asleep, and the baby often cries afterward. The history may also include recent developmental regression and poor eye contact or head control. It is critical to have a low threshold of suspicion to evaluate infants with jerking or convulsions urgently, as timely diagnosis and treatment (within days of first events is ideal) are key to the best long-term outcomes. This seizure type has unique treatments requiring neurologist involvement, with ongoing monitoring by PCP for side effects.

If you are concerned that your patient may have infantile spasms, please call the physician referral line to urgently discuss the patient with our providers. They may be appropriate for an urgent or emergent visit with neurology, and the baby may require an inpatient stay for evaluation and to start treatment.

Physical Exam

The physical exam should always include the vital signs (including the head circumference), cardiopulmonary exam and a skin exam looking for hyperpigmented or hypopigmented birthmarks.

The neurological exam should include at least the following evaluations:

• Assessment of patient’s mental and developmental status
• Cranial nerve examination to include pupillary reflexes, facial sensation and facial symmetry
• Symmetry of muscle tone, strength (may be as subtle as arm or leg drift) or deep tendon reflexes
• Sensation
• Gait, arm and leg coordination

Initial Counseling

Families and patients are often very anxious about this unexpected event and the possibility of seizures or epilepsy. However, most healthy children who experience a first unprovoked seizure will have few or no recurrences. In one study of otherwise healthy children who presented with a first-time seizure:

• 46% had one or more recurrences during the next 10 years
• 81% of the children had no more than 4 seizures
• Only 10% of children had >10 seizure episodes

However, these statistics apply most accurately to neurodevelopmentally normal children who have a normal physical examination and normal testing; an abnormal physical exam, developmental history, EEG and/or MRI increase the risk of seizure recurrence.

In children with autism or other neurodevelopmental disorders, convulsive events are more likely than staring spells to be seizures, and they are more likely to have an abnormal EEG whether the event of concern was a seizure or not. Clinical context becomes important to determine whether these children’s events are seizures.

Additional Resources

• New Primary Care Curriculum // International League Against Epilepsy (ilae.org)
• Understanding Pediatric Epilepsy (aap.org)
• Epilepsy/seizure algorithm
• Related article: An Awake Brain Surgery at Seattle Children’s Stops Jasmine’s Seizures – On the Pulse (seattlechildrens.org)

In case you missed it, view our June CME 2 video recording, “Advances in Genetic Diagnostics and Precision-Based Medicine,” featuring Dr. Ghayda Mirzaa.

Save the Date for our 2023 Epilepsy Symposium “Improving Pediatric Outcomes: Advances in Diagnosis, Management and Treatment:” Saturday, October 14, 2023. Join us for presentations from a multidisciplinary panel of experts from Seattle Children’s Neurology, Epilepsy, Neurosurgery and Genetics Programs. Medical professionals and caregivers of children with epilepsy are welcome to attend. Registration is required. Learn more.