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Seizures in Children

By

M. Cristina Victorio

, MD, Northeast Ohio Medical University

Last full review/revision Mar 2020| Content last modified Mar 2020
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Seizures are a periodic disturbance of the brain’s electrical activity, resulting in some degree of temporary brain dysfunction.

  • When older infants or young children have seizures, they often have typical symptoms, such as shaking or jerking of part or all of the body, but newborns may only smack their lips, chew involuntarily, or periodically go limp.

  • Electroencephalography (EEG) is used to diagnose the disorder, and blood and urine tests, brain imaging, and sometimes a spinal tap are done to try to identify the cause.

  • When a child has a convulsion, parents or other caregivers should try to protect the child from harm—for example, by keeping the child away from stairs, sharp objects, and other potential hazards.

  • Treatment is focused mainly on the cause, but if seizures continue after the cause is treated, children are given antiseizure drugs.

Seizures are an abnormal, unregulated electrical discharge of nerve cells in the brain or part of the brain. This abnormal discharge can cause

  • Convulsions

  • Involuntary movements

  • Altered awareness

  • Abnormal sensations

Convulsions are violent, involuntary, jerking and/or stiffening of muscles in a large part of the body.

Epilepsy is not a specific disorder but refers to a tendency to have recurring seizures that may or may not have an identifiable cause.

Seizures in children are often similar to seizures in adults. However, some types of seizures, such as febrile seizures and infantile spasms, occur only in children.

Certain conditions in children, such as breath-holding spells and night terrors, may resemble seizures but do not involve abnormal electrical activity in the brain and thus are not seizures.

Status epilepticus

Status epilepticus refers to a single long-lasting seizure or several shorter seizures that occur without the child regaining consciousness between seizures. Seizures that last more than about 30 minutes are considered status epilepticus. Children with status epilepticus are at risk of brain and other organ damage, as well as breathing failure, hence prompt treatment of seizures lasting more than 5 minutes is necessary.

Causes

In newborns, seizures may be caused by

  • Temporary metabolic abnormalities, such as a low blood sugar level

  • A serious disorder, such as a brain malformation, injury of the brain during pregnancy, lack of oxygen during birth, or a serious infection

  • Inherited disorders that result from mutations in a gene such as a hereditary disorder of metabolism

  • Use of certain drugs by the mother during pregnancy

Seizures caused by hereditary disorders of metabolism typically start during infancy or childhood.

Table
icon

Some Causes of Seizures in Newborns, Infants, and Children

Type

Disorder

General disorders

High fevers

Infection in the blood (sepsis)

Perinatal asphyxia (not getting enough oxygen), as may occur during labor or delivery

Brain disorders

Bleeding (hemorrhage) within the brain

Infections, such as encephalitis or meningitis

Gene disorders that affect nerve functions in the brain

Tumors (rarely)

Metabolic disorders

Hereditary disorders that affect the processing (metabolism) of amino acids, fats, or carbohydrates

Temporary abnormalities in blood levels of sugar (glucose), calcium, magnesium, vitamin B6, or sodium

Drugs

Use of drugs (such as cocaine, heroin, or the sedative diazepam) by the mother during pregnancy, resulting in withdrawal in the infant

Accidental ingestion of a drug or poison by an infant or young child

In older infants and children, the cause of seizures may be unknown.

Febrile seizures are fairly common in young children.

Seizures may run in families.

Symptoms

In newborns, seizures may be difficult to recognize. Newborns may smack their lips or chew involuntarily. Their eyes may appear to gaze in different directions. They may periodically go limp and/or stop breathing.

In older infants or young children, one part or all of the body may shake, jerk, or tighten up. The limbs may move without purpose. Children may stare, become confused, have unusual sensations (such as numbness or tingling) in parts of the body, or have unusual feelings (such as feeling very afraid for no reason).

Did You Know...

  • Sometimes seizures cause children to simply stare or appear confused instead of causing convulsions.

Prognosis

The prognosis depends on the cause.

A seizure itself does not appear to damage the brain or cause lasting problems unless it continues for more than about an hour (most seizures last only a few minutes). However, many disorders that cause seizures can cause lasting problems. For example, some disorders can interfere with the child's development. Whether some types of recurring seizures can affect the developing brain is debated.

Diagnosis

  • Electroencephalography

  • Other tests to check for a cause depending on the child's symptoms and physical examination

Children who have seizures are evaluated immediately to check for serious causes and causes that can be corrected.

If a child has had a seizure, doctors do a physical examination. They also ask the parents whether any family members have had seizures.

Electroencephalography (EEG—a test that records brain waves using sensors placed on the scalp) is done to check for abnormal electrical activity in the brain. EEG is done while infants or children are awake and while they are asleep.

Doctors do other tests to check for a cause based on the child's symptoms and the results of the examination. These tests may include

  • Measurement of the oxygen level in the blood using a sensor clipped on a finger (pulse oximetry) to determine whether the oxygen level is low

  • Blood tests to measure blood sugar (glucose), calcium, magnesium, sodium, and other substances to check for metabolic disorders

  • A spinal tap (lumbar puncture) to obtain a sample of the fluid around the brain and spinal cord (cerebrospinal fluid), which is analyzed and checked for brain infections and other disorders

  • Cultures of blood and urine to check for infections

  • Brain imaging tests, such as computed tomography (CT) or magnetic resonance imaging (MRI), to check for malformations of the brain, bleeding, tumors, and other structural damage to brain tissue (for example, by a stroke)

  • Genetic tests to look for genetic disorders that may be associated with seizures

Treatment

  • Immediate measures

  • Treatment of the cause

  • Antiseizure drugs

  • Sometimes surgery or other procedures if drugs are ineffective

Treatment of seizures in infants and children is focused mainly on the cause of the seizure. For example, children who have a bacterial infection are given antibiotics, and children who have low a level of sugar (glucose) in their blood are given glucose. Other treatable causes include viral infections, some tumors, and abnormal levels of sodium, calcium, and magnesium in the blood.

Sometimes children need to take drugs to control seizures (antiseizure drugs), particularly if the cause cannot be eliminated.

If drugs are ineffective, surgery may be recommended.

Immediate measures

When a child has a convulsion, parents or other caregivers should do the following to try to protect the child from harm:

  • Lay the child down on one side.

  • Keep the child away from potential hazards (such as stairs or sharp objects).

  • Do not put anything in the child’s mouth and do not try to hold the child’s tongue.

Did You Know...

  • Contrary to popular opinion, people should not put anything in the mouth of someone who is having a seizure.

After the seizure ends, parents or other caregivers should do the following:

  • Stay with the child until the child is fully awake.

  • Check whether the child is breathing and, if breathing is not apparent, start mouth-to-mouth rescue breathing (if the child is having convulsions, attempting rescue breathing is unnecessary and can injure the child or the rescuer) and alert emergency medical services.

  • Do not give any food, liquid, or drug by mouth until the child is fully awake.

  • Check for fever and, if present, treat it.

Fever can be lowered by giving the child acetaminophen by suppository placed in the rectum if the child is unconscious or too young to take drugs by mouth or by giving acetaminophen or ibuprofen by mouth if the child is conscious. Also, warm clothing should be removed.

An ambulance should be called if any of the following occur:

  • This is the child's first seizure.

  • The seizure lasts more than 5 minutes.

  • The child is injured during the seizure or has difficulty breathing after the seizure.

  • Another seizure occurs immediately.

All children should be taken to the hospital emergency department the first time they have a seizure. For children who are already known to have a seizure disorder, parents should discuss in advance with the doctor when, where, and how urgently evaluation is required if another seizure occurs.

Doctors usually give drugs to end a seizure that lasts 5 minutes or more to prevent status epilepticus. Drugs to end seizures include the sedative lorazepam or the antiseizure drugs phenobarbital, fosphenytoin or levetiracetam by vein (intravenously). If a drug cannot be given intravenously, diazepam gel may be applied to the rectum, or midazolam liquid may be given into the nose (intranasally). Diazepam and midazolam are sedatives similar to lorazepam that can help stop seizures. Children who have received these drugs or with status epilepticus are carefully monitored for problems with breathing and blood pressure.

If children continue to have seizures after the cause is treated, they are given antiseizure drugs intravenously. They are then closely observed to check for possible side effects, such as slowed breathing.

If antiseizure drugs control the seizures, they may be stopped before children are discharged from the nursery or hospital. Whether antiseizure drugs are stopped depends on the cause of the seizures, their severity, and the results of the EEG.

Antiseizure drugs

If children have only one seizure, they usually do not need to take an antiseizure drug (see Using Drugs to Treat Seizures in Children). Antiseizure drugs are used if seizures recur or are likely to recur.

The antiseizure drug dose is usually increased if a standard dose does not adequately control seizures. The dose may also be adjusted as children grow and their weight increases. Another antiseizure drug may be added or substituted if the first one was only partly effective or had bothersome side effects. Antiseizure drugs can interact with other drugs, so parents should tell their child's doctor all the drugs and supplements the child is taking.

At times, doctors do blood tests to measure the level of the drug, which helps determine whether the dose is correct and whether the child is taking the drug. These tests are sometimes repeated when the dose is changed, when the child has grown significantly, or when a new drug is started.

The need to continue taking antiseizure drugs depends on what caused the seizures and how long children have been seizure-free. Most children continue taking antiseizure drugs until they have had no seizures for 2 years. The risk of having a seizure after 2 seizure-free years is less than 50%. However, having another disorder that affects the brain and nerves (such as cerebral palsy) increases the risk of having another seizure.

When antiseizure drugs are to be stopped, the dose is reduced over a period of time rather than stopping the drug all at once.

Using Drugs to Treat Seizures in Children

When their child has had a seizure, parents are often concerned that the child may need to take a drug to control seizures (an antiseizure drug). Parents are concerned about side effects, and they know that getting children to take a drug on a regular basis is difficult. Learning more about antiseizure drugs can help parents better participate in decisions about treatment of their child.

Positives:

  • Most children who have had only one seizure do not need to take antiseizure drugs.

  • Doctors can choose from more than 20 antiseizure drugs in their search for one that is appropriate for a particular child.

  • Antiseizure drugs stop or control the seizures in 80% of children.

  • Many children need to take only one antiseizure drug.

  • Most children can eventually stop taking antiseizure drugs.

Negatives:

  • Most antiseizure drugs have side effects, such as dizziness, nausea, unsteadiness, drowsiness, double vision, or rash.

  • Some antiseizure drugs may affect attention span, memory, and school performance while children are taking the drug.

  • Children who take certain antiseizure drugs must have regular blood tests to determine whether the dose is correct or to check for side effects (such as chemical imbalances in the blood).

  • Some newer antiseizure drugs have not been tested in young children (although these drugs often are used in young children and results of that experience are published).

In weighing concerns, parents should remember that preventing further seizures is important because poorly controlled seizures can lead to slowing of mental processing (cognitive delays), emotional and behavioral problems, and poor quality of life. Also, preventing seizures prevents the injuries and accidents that may occur because of a seizure.

To be sure drugs are taken on a regular schedule, parents can do the following:

  • Use a pill box (which contains compartments for each day of the week, for different times of each day, or both).

  • Refill prescriptions before they run out.

  • Encourage the child to take responsibility for taking the drug, but continue to oversee the process until the child is reliable.

  • Discuss in advance with the doctor what to do if the child misses a dose.

Surgery for seizures

Surgery occasionally may be an option if children continue to have seizures while taking two or more antiseizure drugs or if side effects are intolerable. This operation involves surgically removing an area of the brain. It is usually done only when seizures are caused by only one area in the brain and that one area can be removed without significantly affecting the child's ability to function. Sometimes this operation substantially reduces the number of seizures a child has. Tests may be done to help locate the area in the brain that is causing seizures. These tests include the following:

  • MRI to determine the functions of the areas of the brain near the area that is causing the seizures (called functional MRI)

  • Continuous video-EEG (in which brain waves and a video of the child are recorded at the same time)

Before surgery is done, a neurosurgeon and a neurologist explain the risks and benefits of surgery to the parents. Even when surgery reduces the frequency and severity of seizures, many children need to continue to take antiseizure drugs. However, they can usually take lower doses or fewer drugs.

Stimulating the vagus nerve

Stimulating the vagus nerve (the 10th cranial nerve) can sometimes reduce the number of seizures children have. The vagus nerve is thought to have indirect connections to areas of the brain that are often involved in causing seizures. This procedure can be used in children as young as 4 years old. Doctors consider using this procedure when antiseizure drugs are ineffective and epilepsy surgery is not possible.

To stimulate the vagus nerve, doctors implant a device that resembles a heart pacemaker under the left collarbone and connect it to the vagus nerve in the neck with a wire that runs under the skin. The device causes a small bulge under the skin. The operation is done on an outpatient basis and takes about 1 to 2 hours. The device turns on and off all the time and thus periodically stimulates the vagus nerve. The doctor can easily and painlessly change the settings for stimulating the nerve using a magnetic wand placed over the device. Also, when the child senses that a seizure is starting or when a family member sees a seizure begin, a magnet (often worn in a bracelet) can be used to set the device to stimulate the nerve more often.

Vagus nerve stimulation is used in addition to antiseizure drugs. Possible side effects include hoarseness, cough, and deepening of the voice when the nerve is stimulated. Vagus nerve stimulation usually makes the child more alert. Increased alertness may improve attention but sometimes interferes with sleep.

Stimulating the brain

Sometimes, giving electrical stimulation to the part of the brain in which seizures start can interrupt a seizure before it begins or shorten a seizure that has started. The responsive neurostimulation system is a device that looks like a heart pacemaker. It is implanted within the skull. The device is connected by wires to one or two areas in the brain that are causing the seizures. This system monitors the brain's electrical activity. When it detects unusual electrical activity, it stimulates the areas of the brain that are causing the seizures.

The responsive neurostimulation system is used in addition to antiseizure drugs.

Surgery to implant the system requires general anesthesia and typically takes 3 to 4 hours. Children need to stay in the hospital overnight. Many children return to their normal daily activities within a few days.

Children cannot feel the device or the stimulation, and the device can be removed if needed.

Ketogenic diet

A ketogenic diet may be prescribed by the doctor in some situations. A doctor and a dietician must supervise use of the diet. This restrictive diet is very low in carbohydrates and very high in fat. When the body breaks down fat to use for energy, substances called ketones are formed. In some children, the ketones help control seizures. The ketogenic diet must be carefully followed and requires that the amounts of foods be measured precisely. Even one bite or taste of a restricted food can lead to a seizure. Children may have difficulty following such a strict diet. If children who are following a ketogenic diet improve substantially, the diet is often continued for at least 2 years. Side effects of a ketogenic diet may include a low blood sugar level, sluggishness (lethargy), and weight loss. Sometimes the Atkins diet is used instead. It is a less strict form of the ketogenic diet.

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