Seizures in children

1. NEONATAL SEIZURE
Dr.Mirzarahimi
Neonatologist

2.  Seizures are paroxysmal involuntary
disturbance of brain function that maybe
manifested as Impairment of Consciousness,
abnormal motor activity, behavioral
abnormality, sensory disturbance or
autonomic dysfunction.
 Neonates are at particular risk for seizures
because of:
-Metabolic Disturbances.
-Toxic.
- Structural abnormality.
- Infectious Diseases.

3.  Neonatal seizures are dissimilar from those
in children or adults because of:
-Incomplete arborization of axons, and
dedritic processes as well as mylenation are
also incomplete.
 At least five seizure types are recognized in
a new born infant:
1. Focal seizure which usually involves
specific group of muscles secondary to:
-Structural lesions.
-Infection.
-Subarachnoid hemorrhage.

4. 2- Multifocal seizure (clonic):
These seizures are characterized by
random clonic movements of limbs similar
to those seen in normal infants under 34
weeks of gestation. The EEG is most often
unifocally abnormal, the prognosis is
generally good.
3- Tonic seizures:
Divided into general and focal usually
associated with eye deviation or apnea and
most often seen in prematures and carry a
poor prognosis.

5. 4- Myoclonic Seizure:
the manifestations include synchronous
single or multiple slow jerks of upper or lower
limbs or both and are associated with diffuse
CNS pathology, the prognosis is poor.
5- Subtle seizure:
50% of seizures in both term and
prematures.
usually presented as:
Excessive salivation.
Alteration of respiratory rate.
blinking.
nystagmus.

6. -Bicycling or pedalic movements
-Change in skin color.
-apnea due to seizures:
most often has either an:
accelerated or normal heart rate while
apnea due to other cause usually associated
with bradycardia.

7. EEG CLASSIFICATIONS OF NEONATAL
SEIZURES
1- Clinical seizures with a consistent EEG
events. Which includes:
focal clonic.
focal tonic.
some myoclonic seizures.
These seizures are clearly epileptic and are
likely to respond to an anticonvulsants
2- Clinical seizures with inconsistent EEG
events:

8. this is observed with all generalized tonic
seizures, subtle seizures and with some
myoclonic seizures.
Seizures in this category are likely to be of non
epileptic origin and may not require or
respond to anti epileptics.
3- Electrical seizures with absent clinical
seizures:
may develop in comatose infant who are
not on anti convulsants, conversely electrical
seizures may persist in patients with focal
tonic or clonic seizures without clinical signs
after the introduction of an anticonvulsant.

9. ETIOLOGY
1-Hypoxic Ischemic Encephalopathy:
represent 60% - 65% of cases of neonatal
seizures, occurs in babies with severe fetal
distress who are apnic at birth. Seizures
usually occur in the first day of life most often
beginning in the first 12 hours.
2-Intracranial hemorrhage:
Subarachnoid hemorrhage.
Perivetricular hemorrhage.
Subdural hemorrhage.
Intraventricular hemorrhage.

10. 3- metabolic problems:
-hypoglycemia.
-hypocalcemia.
-hypomagnesemia.
-hyponatremia.
-hypernatremia.
-pyridoxin deficiency.
-disorders of metabolism as
phenylketoneurea, hyperglycinemia, urea
cycle disorders and β-alanine abnormalities.
-organic acidemia.
-biotin responsive disorders.
-fructose intolerance disorders.

11. -peroxisomal disorders.
-mitochonderial disorders.
-storage diseases.
4- Infections:
-bacterial meningitis.
-viral infection.
-toxoplasmosis.
-syphilis.
5- Developmental disorders:
-cerebral dysgenesis.
-fakomatosis which include:
neurofibromatosis, sturge weber disease and
tuberous sclerosis.

12. 6- Drug associated seizures:
-narcotic and sedative withdrawal.
-local anesthesia.
-theophyllin.
7- Polycythemia and hyperviscosity.
8- Familial neonatal seizures.
9- Focal infarction.
10- Hypertensive encephalopathy.
11- Idiopathic.

13. Jitterness and Clonus
 Charaterictics of jitterness and clonus that
help to differentiate them from seizures are as
follows:
1- absence of abnormal gaze or eye
movement.
2- provocation by stimulation of the infant
or by stretching a joint in contrast to the usual
spontaneous occurrence of seizures.
3- cessation of movements with passive
fexion or gentle resistant .
4- absence of the fast and slow
components that are characteristics of a
clonic fit.

14. 5- Tremor and Clonus with no associated EEG
abnormality.
6- Repetitive jerks in seizures are at a rate of 2
to 3 per second, whereas clonus tend to be
faster as 5-6 per second.
7- Jitterness and non-seizure clonus not
accompanied by increased blood pressure,
bradycardia, or tachycardia.

15. Treatment
 Treatment of the underlying cause.
 Anticonvulsant therapy:
-phenobarbital.
-phenytoin.
-diazepam.
-lorazepam.
-medazolam.

16. PROGNOSIS
 The overall prognosis in neonatal seizures
is death in 15%.
 Neurologic squally such as mental
retardation, motor deficit in 30%.
 Normal outcome in 50%.
 Chronic seizure disorder will develop in
15%-20% of survivors.

17.  Prognosis is affected by the following
factors:
1. Gestational age.
2. Etiology.
3. Seizure pattern.
4. EEG.
5. Abgar score.
6. Duration of seizures.
7. Association of hypotonia.
8. The presence of tonic or myoclonic
seizures.
9. Early onset of seizures.
10. The need +ve pressure ventilation.

18. GOOD PROGNOSTIC FACTORS
 Seizures free at discharge from hospital.
 Seizures subside within 24 hours.
 Neurological examination is normal with no
abnormal eye movement.
 Return to normal routine feeding within 5
days.
 EEG is not persistently abnormal.

19. BAD PROGNOSTIC FACTORS
 Prolonged and repetitive seizures (more
than 30 minutes).
 Abnormal eye movements.
 Abnormal interictal EEG.
 Abgar score less than 7 at 5 minutes.
 Prematures.
 Early onset of convulsions.

20. Etiology Normal outcome(%)
Subarachnoid hemorrhage 90
Uncertain 75
Early Hypocalcemia 50
Late hypocalcemia 100
Hypoglycemia 33-71
Neonatal Encephalopathy 31-50
IVH 10
Meningitis 11-65
Dysgenesis zero
Prognosis of Seizures
by Etiology

21. Prognosis of seizures by seizure pattern: Normal
outcome(%) by gestational age at birth
Seizure pattern Full term(%) Premature(%)
Focal clonic 100 33
Multifocal 33 33
Generalized 59 41
Tonic 50 36
Myoclonic 0 0
Subtle 57 44