Seizures: Management in children

Epilepsy is the most common neurological condition affecting all ages, including children (Neligan and Sander, 2015). Approximately 600 000 people in the UK live with epilepsy, equivalent to around one in 103 people (YoungEpilepsy, 2020).

Epilepsy and seizures

Epilepsy is not a single condition but a group of many varied ‘epilepsies’. Having epilepsy simply means a tendency to have seizures and having a single seizure does not mean that someone has epilepsy (YoungEpilepsy, 2020).

A seizure is the occurrence of signs or symptoms due to abnormal electrical activity in the brain, which can be triggered by many different causes. This may manifest in a variety of ways; for example, a disturbance of consciousness, change in behaviour, cognition, emotion, motor function or sensation (Fisher et al, 2017). Seizures may be focal, affecting only one part of the brain and on only one side or hemisphere, or be generalised, affecting both sides of the brain. Focal seizures can, however, progress to affect both sides of the brain. See Table 1 below for information on the different types of seizure.

Anti-epileptic drugs

Anti-epileptic drugs are the mainstay of long-term management and prevention of seizures. The choice of drug depends on a number of factors, including the seizure type or epilepsy syndrome, other medications the child may be taking, other medical problems, the child's lifestyle and their preferences (National Institute for Health and Care Excellence [NICE], 2012).

A single drug—monotherapy—is the preferred regime, however this may require trialing a number of different agents until a successful anti-epileptic drug and dose is found for the particular patient. Generally, if one drug has failed to control seizures, or produces intolerable side effects, a second anti-epileptic drug is started alongside the first drug, with the second drug increased to a sufficient or maximum tolerated dose and then the first drug slowly tapered off.

If a number of anti-epileptic drugs as monotherapy have failed, then the use of an additional drug, an adjunct, may be of benefit. See Table 2 for details of first line and adjunct anti-epileptic drugs used for certain seizure types, as recommended by NICE. An anti-epileptic drug can also be selected on the basis of an epilepsy syndrome. Details of these recommendations have not been included, but can be found on the NICE website, Clinical guideline CG137.

‘Epilepsy is the most common neurological condition affecting all ages, including children. Approximately 600 000 people in the UK live with epilepsy.’

As with all medications, anti-epileptic drugs have side effects, some of which can be intolerable to patients. The most frequently experienced side effects for commonly prescribed anti-epileptic drugs are detailed in Table 3.

Anti-epileptic drugs should not be stopped suddenly, and termination of medication should be slowly tapered and closely monitored by a medical professional. Anti-epileptic drugs should be taken regularly to prevent seizures. Dosage is usually twice per day, although some preparations are available as once per day regimes.

First aid measures

Most seizures are unprovoked and start spontaneously, with no prior warning. They normally only last a short period of time and are usually self-terminating, requiring no special treatment or specific management. However, there are certain first aid measures that may be required to keep a child who is having a seizure safe. After the seizure has terminated the child should be reassured and comforted with someone staying with them until they have fully recovered.

Generalised tonic-clonic seizures

It is important to note the time the seizure starts, so its duration can be monitored, as the duration of the seizure dictates the management. For generalised tonic-clonic seizures, where the child is convulsing, first aid measures are to ensure the safety of the child. They should not be moved, unless in immediate danger. Steps to protect the child from any injury to themselves should be made, by moving any objects that could cause harm, and using cushions, pillows or other soft items to place under the head and other body parts that may be moving. The child should not be restrained or held down, or anything placed in their mouth, as this may cause more harm. Once the seizure has finished, the child should be placed on their side, in the recovery position, ensuring their airway is open and they are breathing normally. The child should be monitored until they have fully recovered from the seizure, which may take some time, especially if the seizure has lasted for a number of minutes. After generalised tonic-clonic seizures there is often a postictal state, where the child will be drowsy and not fully conscious. This normally lasts between 5 and 30 minutes, although may be longer if there have been multiple or prolonged seizures. At this stage the child may need to sleep, or lay down and rest and they may experience other symptoms such as confusion, nausea or headaches.

Absence seizures

Absence seizures will often result in the child becoming blank, vacant and very still for a short period of time, typically lasting less than 30 seconds. This is often confused with daydreaming. They do not usually require any intervention and the child will usually fully recover immediately afterwards.

Focal seizures

With focal seizures and occasionally absence seizures, the child may start to wonder around aimlessly, with no awareness of their surroundings. In this case, the child may need someone to accompany them, helping them to avoid bumping into things, as they may have a reduced awareness of their surroundings, and to steer them away from any dangers that may be present. The child should not be restrained, but gently guided. After a period of time they should start to regain their awareness.

Atonic and tonic seizures

These seizures are usually short lived, with the child recovering quickly afterwards. However, as they result in sudden drops (atonic) or complete body stiffening (tonic), they often lead to falls. Atonic seizures often result in the child falling face forward onto the floor, which can cause facial injuries. It is important to check for any injuries resulting from the fall that may require further investigation or treatment.

When to call an ambulance

It is not always necessary to call an ambulance for a child having a seizure, especially if they are known to have frequent seizures and even if emergency medication has been given. There should be a clear plan in place for when an ambulance should be called for children with known frequent or prolonged seizures, especially those who are prescribed emergency medication. However, in some circumstances it is necessary to call an ambulance. An ambulance is required in the following situations:

• If this is the child's first seizure
• If the seizure continues for more than 5 minutes
• If the child has multiple seizures following on from each other with only minimal or partial recovery in-between
• If the child sustains any injury

Emergency medication

In some cases, children may have been prescribed medication to be given in the case of prolonged or multiple seizures, to help in terminating the episode. Medications are only normally prescribed if there has been a previous episode of a prolonged seizure or serial seizures and there should be a clear plan in place about when these are to be used, where they are kept, what dose should be given and who can administer them.

The two medications used are both benzodiazepines, which are quick acting but only work for a short period of time. Both have side effects of sedation and rarely respiratory depression. The most commonly prescribed, midazolam, is given via the buccal route, with the dose measured in a 1 ml syringe and the drug squirted into the mouth between the teeth and lips/cheek. It is rapidly absorbed by the oral mucosa of the mouth, but it should be noted that it should never be squirted beyond the teeth and down into the mouth or throat. Its fast onset and ease of administration makes it the first line and preferred treatment option for emergency medication. Doses vary by age of the child: 1–4 years 5 mg, 5–9 years 7.5 mg, 10–17 years 10 mg. The dose may be repeated after 10 minutes if the seizure has not been terminated (Paediatric Formulary Committee, 2020).

The second option available for rapid termination of seizures in the community is diazepam, another short-acting benzodiazepine. This is given via the rectal route, and as such can be invasive, requiring some level of handling/moving the child to be able to access the appropriate area and can cause embarrassment and distress. For these reasons it is less commonly prescribed. Doses for children increase with age, with a 1-year-old receiving 5 mg, 2–11-year-olds 5–10 mg, 12–17-year-olds 10–20 mg, with a second dose repeated after 10 minutes if the seizure fails to terminate (Paediatric Formulary Committee, 2020).

Conclusion

There are many different types of seizure, and forms of epilepsy, with different drug choices for each. Monotherapy of anti-epileptic drugs is the preferred treatment regime; however, some cases may require multiple anti-epileptic drugs. Emergency medication is available for the treatment of seizures out of hospital but is only used in certain circumstances; otherwise, simple first aid measures are usually all that is required when managing a seizure in the community.

KEY POINTS

• Epilepsy is a common condition and one that school nurses are likely to come across due to the high prevalence in the general population, including in children.
• Antiepileptic drugs are used in the long-term management of epilepsy to prevent and control seizures, with many different drugs available, depending on the seizure type or epilepsy syndrome.
• First aid measures are normally all that is required when a child is having a seizure, with the main aim being to keep the child safe.
• Emergency medications are available for use in the community, to terminate prolonged or multiple seizures, but are only used in certain circumstances.