Brain And Intelligence Development In Children
Development Of Infant
Headache In Children
Epilepsy In Children
• Benal ÇUBUK, MD
EPILEPSY IN CHILDREN
The possible reasons of epilepsy in children include pre-natal brain problems, oxygen deficiency during birth or after, head injury damaging the brain, extraordinary structures in the brain, tumors, long-term seizure with fever, post-brain infection effects such as meningitis or encephalitis.
Epilepsy is a widespread disease. In many cases, clear familial inheritance is not described. In addition to this, increased risk compared to the general population is observed in close relatives of persons having seizures. Some diseases causing symptomatic epilepsy are genetic and clear inheritance is observed in some families.
Types Of Seizure
Epilepsy children have seizures like the adults as generalized seizure and partial seizure. In generalized seizure, electrical organization disorder covers the whole brain. If a part of brain is affected, it is called as partial seizure. If electrical organization disorder starts in a part of brain and spreads it is called as secondary generalized partial seizure. Some children may have only one type of seizure and others may have two or more types of seizure.
Generalized tonic clonic (Grand mal): It is frequently called as generalized convulsion. It starts with sudden scream, falling down, stiffness of the body and shock as muscles contract. Then it relaxes, strains and relaxes. Inhalation is in the form breathing and may stop for short time. The skin may be bluish. Since muscles relax, urinary bladder and intestine control loss is possible. It generally lasts for 1-2 minutes then normal breathing continues. The child may be confused and tired following the seizure and fall fast asleep. He may complain about aching muscles or tongue beaten.
Absence: It starts with staring blankly suddenly. It lasts for only a few seconds and frequently repeats during the day. Fast opening and closing the eyes, shifting upwards, smacking the mouth may accompany. The child may drop what is in his hands. Black-out is observed during the seizure. Seizure is frequently confused with dreaming or lack of attention.
Atonic (Drop attacks): Sudden loss of muscle tone may result in sudden falling down of the child. In some children, it is limited to nodding. Time of seizure may vary between a few seconds or one minute. Drop attacks may lead to injury due to severity of falling down. Protective helmets can be helpful when children play outside.
Myoclonic : Sudden, short involuntary muscle contraction occurs. It may be mild and affect a part of the body or result in sudden falling down of the child. It may occur in a seizure or series of seizures.
Simple partial : Seizures generally trigger the movement in one side of the body. However, the child is aware of what is happening. It may result in spasm movements affecting fingers, toes or the whole of a part of the body. It may turn into generalized convulsion. Partial seizures affecting senses may lead to different look of objects, hearing, tasting differently, fear or non-feeling. These effects may be stomachache, nausea, anxiety or fear.
Complex partial: Mental fog or black-out is observed. The child doesn’t know what he has done or where he is during the seizure. It often begins with staring and continues with smacking and repeating meaningless and mechanic movements. The child may pick his clothes, take and throw objects, try to take off his clothes. He can run, seem as afraid, struggle with the ones holding him or shake hardly. The same movements may not be observed in every seizure. It lasts for only 1-2 minutes however, child may be confused, afraid for a long time. He doesn’t remember what has happened after the seizure. Partial seizures may occur in any part of the brain. Symptoms to be experienced by the child depend on the location of seizure. Most complex seizures arise from temporal lobe of the brain and have similar symptoms as above-mentioned. If seizures originate from frontal lobe, dysfunction or fatigue will be observed. It occurs in sleep mostly. Movements of lamenting, fear, shouting, cycling in the legs are observed. In seizures originating from occipital lobe, it is possible for the child to see unreal things.
Some children with epilepsy show a number of similarities in terms of onset age of the seizure, type of seizure, electroencephalography (EEG) findings, response to the treatment, effect of epilepsy on them in time and their future. These children are described as “having special epilepsy syndrome”. New syndromes are defined continuously. Some widespread syndromes are as follows:
Childhood absence epilepsy (Petit Mal Epilepsy): It is observed in the rate of 2-4% of epileptic children. It starts between the ages of 3-10. The patient stares at single point and becomes inactive and may blink during the seizure. Total black-out accompanies the seizure. The patient can’t perceive what is happening during the seizure. Seizures are observed in 40% of patients with this diagnosis at about 18 years old. Generalized convulsion may be seen during the course of the disease.
Juvenile myoclonic epilepsy: Seizures begin in adolescence. Myoclonic seizures followed by waking up are typical. During these seizures, the patient may drop the object in his hand due to jumping. Moreover, absence and generalized convulsions may be observed. Seizures can be controlled with medication well however, the disease lasts for lifetime.
Childhood benign partial epilepsy: It begins between the ages of 3-13. Seizures repeat in sleep typically. It may start with numbness of mouth, lip, gingival and the patient can’t speak during the seizure. Saliva is observed in the sides of mouth. Clonic spasm may be seen in a half of the face and in the arm on the same side. The patient is conscious during seizure. If seizure turns into generalized convulsion in sleep, the consciousness may be affected. Examinations of the children are normal. Seizures stop at the age of 15 in 95% of cases.
Infantile spasms (WEST Syndrome): These are a group of myoclonic fast spasms making the baby double and moving forwards by closing or opening the arms. The child has a special EEG called as “hypsarrhtymia”. Syndrome begins in the first years of the life. In many children with infantile spasms, developmental delay and other epilepsy types such as “Lennox- Gastaut Syndrome” may develop. Steroid hormones, ACTH and anti-epileptic medicines can be used for treatment.
Lennox - Gastaut Syndrome: Treatment is difficult. It is the mixed seizure syndrome consisting of absence seizures, tonic seizures resulting in stiffness (generally while sleeping), drop attacks, traumatic seizures when waking up and special EEG. It starts between the age of 1 and 5. Moreover, a number of rare syndromes are seen related to the seizures. This group includes Rasmussen syndrome originating from a part of the brain and Landau Kleffner syndrome resulting in the loss of speech with seizures.
Seizures And Fevers
Febrile (due to fever) seizures affect many children between the month of 3 and age of 6. Febrile seizures are not the same as the epilepsy. In spite of it, in rare cases, febrile seizures may be the first seizures of the epilepsy to occur in the future. Febrile seizures occur when the fever of the child rises fast generally above 39-40°C or more. Febrile seizure history is observed in the family frequently. It is widespread in about the age of 1,5 and affects 3-4% of children, febrile seizures repeat in 30-40%. However, this tendency will be eliminated as the child grows up. Epilepsy will develop in about 3% of febrile seizure children. Fever (in addition to narcotic drug, some medicines and sleeplessness) may trigger seizures in children with epilepsy.
Seizures And Other Cases
Having a seizure is the sign of an underlying condition in the brain. In some cases, it is the single sign of brain disease. In other cases, it may be one of the many symptoms of that disease. Tuberculosis, cerebral palsy, mental retardation, autism and neurofibromatosis are among widespread brain involvement to be related to seizures. Epilepsy related to other brain disorders is treated similarly as the epilepsy for unknown reason.
Don’t forget that any kinds of treatments can be administered with the decision of your doctor. Childhood epilepsy is mostly treated with anti-epileptic or anti-convulsant medicines called as anti-seizure medicines. In some cases, surgery, ketogenic diet or stimulation of vagus nerve (VNS) can be tried.
Drug use: children use the same drugs as the adults. Drugs can be prescribed in tablet, drop, capsule or syrup. These drugs are prepared to prevent seizures. Some of them are successful for limited type of seizure. Others have wider effect range. If possible, physician tries to control seizures with one drug. In addition to this, some children may have to use more than one drug. When drugs are used regularly and protect the level of effect in the blood of child, children will react to the treatment well. Not having seizure doesn’t mean that medication is not necessary any more. Most of children need treatment at minimum level for years. Consult your physician certainly before stopping anti-epileptic drug. Partial administration of treatment or stopping treatment suddenly may result in serious increase of seizure frequency.
Surgery: If medication can’t control the seizure of the child, child may be a candidate for surgery. The type of most widespread epilepsy surgery is to excise small part of brain where the seizure begins. Sometimes, wider areas may be excised. Other type of surgery implemented less is blocking nerve tracks in the brain to prevent spread of seizure from one part of the brain to the other part.
Ketogenic diet: If the seizure of child can’t be controlled by the medication, a diet with high fat and low carbon hydrate and restricted calorie may be recommended by the physician. This diet is called as ketogenic diet. Ketogenic diet requires team work. Family, doctor, dietitian, training nurse team and child if he is old enough should make sure that diet and side effects are followed.
Warning: Ketogenic diet is a serious treatment method. This diet is not a diet followed alone. If the patient is not under the supervision of a doctor or dietitian, it shouldn’t be implemented.
Stimulation of vagus nerve (VNS) : Stimulation of vagus nerve is a new treatment method to be tried when seizures can’t be controlled by another methods. Treatment is to send small, regular electric energy discharge to vagus nerve (a wide nerve to the brain directly in the neck). The energy is supplied by small generator like a disk. This generator is in the size of chronometer and implanted in the skin under the rib cage surgically. Generator is connected with lead wire under the skin tips of which are wrapped around vagus nerve. Operation of implantation of this device can be performed by hospitalization or as ambulatory.