Seizures (convulsive syndrome) in children

Convulsive syndrome in children is a typical manifestation of epilepsy, spasmophilia, toxoplasmosis, encephalitis, meningitis and other diseases. Seizures occur with metabolic disorders (hypocalcemia, hypoglycemia, acidosis), endocrinopathy, hypovolemia (vomiting, diarrhea), overheating.

To the development of seizures can result in many endogenous and exogenous factors: intoxication, infection, trauma, CNS diseases. In newborns, the cause of seizures may be asphyxia, hemolytic disease, congenital defects of the central nervous system. 

[1], [2], [3]

Symptoms of a convulsive syndrome

Convulsive syndrome in children develops suddenly. There is motor excitement. The look becomes wandering, the head throws back, the jaws close. Characteristic is the flexion of the upper limbs in the wrist and elbow joints, accompanied by the straightening of the lower limbs. A bradycardia develops. It is possible to stop breathing. The color of the skin changes, up to cyanosis. Then, after a deep breath, the breathing becomes noisy, and cyanosis gives way to pallor. Seizures can be clonic, tonic, or clonic-tonic in nature, depending on the involvement of brain structures. The smaller the age of the child, the more frequent generalized seizures occur.

How to recognize a seizure syndrome in children?

The convulsive syndrome in infants and young children is usually of a tonic-clonic nature and occurs mainly in the case of neuroinfections, toxic forms of acute respiratory viral infections and OCD, and less often in epilepsy and spasmophilia.

Seizures in children with fever are probably febrile. In this case, the family of the child is free of patients with convulsive attacks, there is no indication of convulsions in the anamnesis at normal body temperature.

Febrile convulsions usually develop between the ages of 6 months to 5 years. At the same time, their short duration and low frequency (1-2 times during the fever period) are characteristic. Body temperature during an attack of seizures more than 38 ° C, there are no clinical symptoms of an infectious brain injury and its membranes. On the EEG, seizures of focal and convulsive activity are not detected outside the seizures, although there is evidence of perinatal encephalopathy in the child.

At the heart of febrile seizures lies the pathological reaction of the CNS to the infectious-toxic effect with increased convulsive readiness of the brain. The latter is associated with a genetic predisposition to paroxysmal conditions, a structurally unstable brain injury in the perinatal period, or due to a combination of these factors. 

The duration of an attack of febrile seizures, as a rule, does not exceed 15 minutes (usually 1-2 minutes). Usually, a seizure occurs at the height of the fever and is generalized, which is characterized by a discoloration of the skin (blanching combined with various shades of diffuse cyanosis) and the rhythm of breathing (it becomes hoarse, more rarely - superficial).

In children with neurasthenia and neurosis affective-respiratory convulsions occur, the genesis of which is due to anoxia, in connection with a short-term, spontaneously resolving apnea. These cramps develop mainly in children aged 1 to 3 years and are conversion (hysterical) attacks. Occur usually in families with a hyperope. Attacks may be accompanied by loss of consciousness, but children quickly get out of this condition. Body temperature with affective-respiratory convulsions is normal, there are no signs of intoxication.

Convulsions accompanying syncopal conditions, threats to life do not represent and treatment does not require. Muscle contractions (krampi) arise as a result of metabolic disorders, usually the exchange of salts. For example, the development of repeated short-term seizures between 3 and 7 days of life ("fifth day cramps") is explained by a decrease in zinc concentration in newborns.

With neonatal epileptic encephalopathy (Otahara syndrome), tonic spasms develop, appearing in series both during the waking period and in sleep.

Atonic cramps are manifested in falls due to a sudden loss of muscle tone. With the Lennox-Gasto syndrome, the muscle tone supporting the head suddenly loses its tone, and the baby's head falls. The Lennox-Gastaut syndrome makes its debut at the age of 1-8 years. Clinically, it is characterized by a triad of seizures: tonic axial, atypical absences and miathonic falls. Attacks occur with high frequency, often epileptic status, resistant to treatment.

Syndrome Vesta debuts in the first year of life (an average of 5-7 months). Attacks occur in the form of epileptic spasms (flexor, extensor, mixed) affecting both axial muscles and limbs. Typical short duration and high frequency of attacks per day, their grouping in the series. They note the delay of mental and motor development since birth.

Emergency care for convulsive syndrome in children

If convulsions are accompanied by severe violations of respiration, circulation and water-electrolyte metabolism, i.e. Manifestations that directly threaten the life of the child, treatment should begin with their correction.

For the cessation of seizures, preference is given to drugs that cause the smallest respiratory depression, midazolam or diazepam (seduxen, Relanium, and Relium), as well as sodium oxybate. A quick and reliable effect is the administration of hexobarbital (hexenal) or thiopental sodium. In the absence of the effect, it is possible to use an oxyacid anesthetic with the addition of halothane (fluorotan).

When the phenomenon of severe respiratory failure shows the use of prolonged ventilation with the use of muscle relaxants (better atracurium bezilat (tramium)). In newborns and infants with suspicion of hypocalcemia or hypoglycemia, glucose and calcium gluconate must be administered, respectively.

[4], [5], [6]

Treatment of seizures in children

According to most neurologists, it is not recommended to prescribe long-term anticonvulsant therapy after the first convulsive paroxysm. Single convulsive attacks that occur against the background of fever, metabolic disorders, acute infections, poisoning can be effectively stopped in the treatment of the underlying disease. Preference is given to monotherapy.

The main treatment for febrile seizures is diazepam. It can be used intravenously (sibazone, seduxen, relanium) in a single dose of 0.2-0.5 mg / kg (in children it was 1 mg / kg early), rectally and inside (clonazepam) at a dose of 0.1-0.3 mg / (kgsut) for several days after the seizures or periodically for their prevention. With prolonged therapy, phenobarbital (single dose 1-Z mg / kg), sodium valproate is usually prescribed. The most common oral anticonvulsants are finlepsin (10-25 mg / kg per day), antepeptin (0.1-0.3 mg / kg / day), sulexil (10-35 mg / kg per day), diphenine (2- 4 mg / kg).

Antihistamines and antipsychotics increase the effect of anticonvulsants. With convulsive status, accompanied by a violation of breathing and the threat of cardiac arrest, it is possible to use anesthetics and muscle relaxants. In this case, the children are immediately transferred to the ventilator.

With an anticonvulsant goal under conditions of ICU, GHB is administered at a dose of 75-150 mg / kg, fast-acting barbiturates (thiopental sodium, hexenal) in a dose of 5-10 mg / kg, etc.

In neonatal and infantile (afebrile) convulsions, the drugs of choice are phenobarbital and diphenin (phenytoin). The initial dose of phenobarbital 5-15 mg / kg-day), supporting - 5-10 mg / kg-day). If the phenobarbital is ineffective, diphenine is administered; the initial dose of 5-15 mg / (kg-day), supporting - 2,5-4,0 mg / (kg / day). Part 1 dose of both drugs can be administered intravenously, the rest - inside. With the use of these doses, treatment should be performed in the intensive care units, since it is possible to stop breathing in children.

Pediatric single doses of anticonvulsants

A drug	Dose, mg / (kg-day)
Diazepam (sibazone, Relanium, Seduxen)	0.2-0.5
Carbamazepine (finlepsin, tegretol)	10-25
Clobazam	0.5-1.5
Clonazepam (antelepsin)	0.1-0.3
Ethosuximide (sulexil)	10-35
Nitrazepam	0.5-1.0
Phenobarbital	4-10
Phenytoin (diphenine)	4-15
Valproate sodium (konvuleks, depakin)	15-60
Lamyctal (lamotrigine):
Monotherapy	2-10
In combination with valproate	1-5

The occurrence of hypocalcemic seizures is possible with a decrease in the level of total calcium in the blood below 1.75 mmol / l or ionized - below 0.75 mmol / l. In the neonatal period of the child's life, seizures can be early (2-3 days) and late (5-14 days). During the first year of life, the most common cause of hypocalcemic seizures in children is spasmophilia, which occurs against the background of rickets. The probability of convulsive syndrome increases with metabolic (for rickets) or respiratory (typical for hysterical attacks) alkalosis. Clinical signs of hypocalcemia: tetanic convulsions, apnea attacks due to laryngospasm, carpopedal spasm, "obstetric hand", positive symptoms of Khvostek, Trusso, Lust.

Effective intravenous slow (for 5-10 min) administration of 10% chloride solution (0.5 ml / kg) or gluconate (1 ml / kg) of calcium. Introduction in the same dose can be repeated in 0.5-1 hour while maintaining clinical and (or) laboratory signs of hypocalcemia.

In newborns, convulsive seizures may be due not only to hypocalcemia (<1.5 mmol / L), but also to hypomagnesemia (<0.7 mmol / L), hypoglycaemia (<2.2 mmol / l), hyperbilirubinemia, pyridoxine deficiency (vitamin B6), which requires emergency laboratory screening, especially if there is no time or technical capacity to confirm the diagnostic versions.