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Evaluating the First Seizure

Evaluating the First Seizure

An adolescent suffers an unprovoked seizure early in the morning after a late night playing video games. A young girl is found unconscious in the bathroom with blue tinged lips. Another young girl experiences a two-minute convulsion in her classroom.

Are these epileptic seizures? How do parents react, and what should they do if another such episode occurs? How should pediatricians advise parents and treat patients in such circumstances? Will the child have to be on medications? If so, for how long?

These first-seizure scenarios and questions pediatric neurologist Eric Kossoff raised at Hopkins Children’s recent Pediatric Trends conference do have answers. Typically, parents are petrified when their child experiences what they perceive to be a seizure, Kossoff noted, and often their initial concern is a brain tumor. Many ask about, or demand, a CT scan.

“The parents are scared, very nervous, and I spend a lot of time reassuring them,” Kossoff said. “A lot of times CT scans are done when the evidence is against it. In general, seizures are not the usual presentation for a new-onset brain tumor.”

Another common concern is that their child is not breathing during a seizure. Some parents ask about performing CPR and putting their child on oxygen.

“All children look terrible when they’re having a seizure, and turn a little blue,” Kossoff said. “But they don’t stop breathing. In fact, it’s almost impossible to have a seizure and not be breathing. You don’t need aggressive CPR.”

The other big concern is anti-epileptic medicines. Most child neurologists typically do not start a child on medicines after one seizure, Kossoff noted. Nonetheless, he approaches the issue head on: “I address their concern, ask ‘What is your concern if we decide to start medications?’”

Parents may mention a distant relative or a friend of a friend who suffered a seizure and had a bad experience with anticonvulsants, Kossoff explained. Or maybe they read something frightening about epilepsy on the Internet. That’s why it’s important, he added, for pediatricians to explain upfront what epilepsy is and the effects and side-effects of anticonvulsant medicines.

“Epilepsy is a scary word, and to dispel the myths I do a lot of education during that first visit,” Kossoff said. “I explain that there’s a lot of electrical activity in the brain and that a seizure that causes an involuntary muscle movement is like static on your television set. There’s no treatment that makes the static go away, only time can do that, but we can raise the threshold or point at which the static happens so that it’s less likely to happen. Most families understand that.”

Of the 20 or so seizure syndromes, Kossoff noted, there are three very important conditions for general pediatricians to be aware of: childhood absence epilepsy, characterized by brief staring and spells; benign rolandic epilepsy, marked by face and shoulder twitching after falling asleep; and juvenile myoclonic epilepsy (JME), which afflicts adolescents and rarely remits without anticonvulsants. Lab studies and EEG should be performed in such suspected cases, but head CTs are not necessary. Unless the patient is an infant and you’re worried about meningitis, a spinal tap is usually not necessary. A good history, Kossoff added, is better than an array of tests.

Generally, there’s a 50 percent chance of the seizure recurring, Kossoff said, most often within six months of the first seizure. But certain flags, like an abnormal EEG or MRI changes, may raise the risk of recurrence to as high as 90 percent.

Do anticonvulsants help? Kossoff noted that several prospective studies have found no evidence that treating the first seizure affects long term prognosis, though treatment could be considered if the EEG pattern indicates a high likelihood of recurrence. Most anticonvulsants are well tolerated and easily given in chewable or liquid preparations. With anticonvulsants, start slowly and build up the dose over 1 to 2 weeks, and check the patient’s labs in 4 to 6 months.

Pediatricians can provide information in their clinic to make the child neurologist’s first seizure evaluation more expeditious, and to effectively counsel parents about the risk of recurrence and how to manage seizures. When the child has a seizure, Kossoff said, better to back away rather than everyone jump in and intervene. Parents can try to make their child comfortable, help the child lie down on his or her side and rest. If the seizure lasts for more than 5 minutes, rectal valium may be used to cease the seizure. If the seizure lasts more than 10 minutes, then parents should call for help.

Also, pediatricians can advise parents of the child with recurring seizures that they are not alone – in a typical school you would find around ten children who have epilepsy. Kossoff recommends that parents not restrict their child’s activities nor change their normal routines; even video games are usually okay.

“Doing things like taking your child out of school,” Kossoff said, “can be more detrimental than having epilepsy.”

For more information about the First Seizure Clinic at Hopkins Children’s, call 410-955-9100.

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