Pediatric presentation
Seizure in children
Was it a seizure, was it the first, was there a fever, and what age is the child: four questions that carry most of the decision.
What are you worried about?
- Status epilepticus
- Meningitis or encephalitis behind a febrile seizure
- Hypoglycemia, hyponatremia, hypocalcemia
- Non-accidental head injury in the infant
- A structural lesion behind a focal seizure
Differential, by age
Newborn birth to 28 days
- Hypoxic-ischemic encephalopathy
- Hypoglycemia and hypocalcemia
- Meningitis or sepsis
- Intracranial hemorrhage
- Inborn errors of metabolism
- Benign neonatal seizures
Infant 1 to 12 months
- Febrile seizure (from 6 months)
- Meningitis
- Non-accidental head injury
- Hyponatremia from dilute formula
- Infantile spasms
Toddler 1 to 3 years
- Febrile seizure (peak 12 to 18 months)
- Meningitis
- Ingestion
- Epilepsy syndromes
- Breath-holding spells (not seizures)
Preschool 3 to 5 years
- Febrile seizure (up to 5 to 6 years)
- Epilepsy
- Hypoglycemia
- Head injury
School age 6 to 11 years
- Epilepsy, including childhood absence epilepsy
- Syncope mistaken for seizure
- Head injury
- Tumour
Adolescent 12 to 17 years
- Juvenile myoclonic epilepsy
- Syncope
- Substance use or withdrawal
- Psychogenic non-epileptic events
- Sleep deprivation triggers
Key history
- A witness description: what the child was doing, how it started, focal features, eye deviation, duration, colour, incontinence, the recovery
- Fever, and the illness around it; recent head injury; possible ingestion
- Previous events, family history of febrile seizures or epilepsy, developmental history
- Feeding and formula preparation in the infant; medications in the house
- Triggers in the adolescent: sleep, flashing lights, alcohol, missed medications
Key examination
- Airway, breathing, circulation, glucose, in that order, before the history
- Level of consciousness and its trend after the event (a prolonged postictal state or a focal deficit is a red flag)
- Signs of meningitis: fontanelle, neck stiffness in the older child, rash
- Head circumference, fundi, skin (neurocutaneous markers), signs of injury
- Full neurological examination once recovered
Red flags
- Seizure lasting over 5 minutes, or repeated without recovery
- Focal seizure, focal deficit after, or a prolonged postictal state
- Signs of meningitis or a bulging fontanelle, or any febrile seizure under 12 months with an incomplete examination
- Age under 6 months or over 6 years for a 'febrile' seizure
- A history that does not fit, bruises, retinal hemorrhages
- Developmental regression
Initial investigations
- Bedside glucose immediately; sodium, calcium and magnesium in the infant or the prolonged seizure
- A simple febrile seizure in a well child needs no investigation for the seizure itself; find the source of the fever
- Lumbar puncture when meningeal signs are present, when the examination is unreliable, or after a complex febrile seizure with concern
- Neuroimaging for focal seizures, focal signs, head injury, or a persistent altered state; an electroencephalogram for recurrent afebrile seizures, not after a first febrile one
How to interpret them
- Simple febrile seizure: generalized, under 15 minutes, once in 24 hours, 6 months to 5 years, developmentally normal
- Complex: focal, over 15 minutes, or recurrent within 24 hours, and the threshold for looking further drops
- A low sodium in a formula-fed infant is a preparation question before it is anything else
When the child is deteriorating
- Status: benzodiazepine at 5 minutes, repeat at 10, then a second-line agent; airway and glucose throughout
- Treat the treatable: glucose, sodium, calcium, infection
- A child who is not waking up is a child with an ongoing problem: a non-convulsive status, a bleed, an encephalitis
Cases and practice
He went stiff and shook, and now he will not wake up properly20 months old · A 20-month-old with a fever since the morning had a two-minute convulsion at home. His parents thought he was dying.Collapsed during the 400 metres15 years old · A 15-year-old runner collapsed mid-race and came round within a minute. Her coach says she 'just fainted'. She has fainted once before, in a swimming pool.
Conditions under this presentation
The adult frame, for contrast