Seizure Disorder
Epilepsy is a common neurologic disorder which can begin at any age. It’s not a single disorder but rather a wide spectrum of complications. All types of epilepsy share an uncontrolled electrical discharge from nerve cells in the cerebral cortex. This is the part of the brain that integrates higher mental functions, general movement, and the functions of the internal organs in the abdominal cavity, perception, and behavioral reactions.
A child's brain contains billions of nerve cells. Normally, the brain continuously generates tiny electrical impulses in an orderly pattern. These impulses travel along the network of nerve cells, called neurons, in the brain and throughout the whole body via chemical messengers called neurotransmitters. Seizures occur when there's a sudden change in the normal way the brain cells communicate through electrical signals.
Epilepsy is a condition in which there is a problem with the brain that causes long-term seizures in the child. In epilepsy the brain's electrical rhythms have a tendency to become imbalanced, resulting in recurrent seizures. In patients with seizures, the normal electrical pattern is disrupted by sudden and synchronized bursts of electrical energy. During a seizure, some brain cells send abnormal signals, which stop other cells from working properly. Seizures interfere with the child's normal brain functions. This abnormality may cause temporary changes in sensation, behavior, movement or consciousness.
Some people use the term "seizure disorder" instead of "epilepsy" to describe this condition. Both mean an underlying tendency to experience seizures. Two or more seizures must occur before a person can receive the diagnosis of epilepsy. Epilepsy can begin at any time of life but it is most common in children under five years. Although epilepsy varies from person to person, children with epilepsy generally have seizures that respond well to medication and they enjoy a normal and active childhood. More that half will outgrow their seizures as they mature, while others may have seizures that continue into adulthood. For some, it will be a temporary problem, easily controlled with medication, outgrown after a few years. For others, it may be a lifelong challenge affecting many areas of life.
Prevalence
About 2.5 million people in the United States have epilepsy, and as many as 9 percent of the entire population may experience a seizure at some point in their lives. Epilepsy is a variable disorder affecting individuals in different ways. Some children with epilepsy may, at times, experience learning or behavior problems. About 326,000 American children under the age of 14 have epilepsy. The incidence of seizures is high before the child's first birthday. It affects children at different ages, and in different ways. Medical treatment of childhood epilepsy is getting better, and research toward a cure continues.
Possible Causes
The reasons why epilepsy begins are different for people of different ages. But what is known is that the cause is undetermined for about half of all individuals with epilepsy. Many of the predisposing factors have been identified, including brain damage resulting from malformations during brain development, head trauma, other penetrating wounds of the brain, brain tumor, high fever, bacterial or viral encephalitis, intoxication, and acute or inborn disturbances of the metabolism. Hereditary or genetic factors also play a role.
Anything that disturbs the normal pattern of neuron activity from illness to brain damage to abnormal brain development can lead to seizures. Epilepsy may develop because of an abnormality in brain wiring, an imbalance of nerve signaling chemicals called neurotransmitters. In some cases, the brain's attempts to repair itself after a head injury, or other problem may inadvertently generate abnormal nerve connections that lead to epilepsy.
Epilepsy Risk Factors
∙ Premature birth or low birth weight
∙ Trauma during birth (such as lack of oxygen)
∙ Seizures in the first month of life
∙ Abnormal brain structures at birth
∙ Bleeding into the brain
∙ Abnormal blood vessels in the brain
∙ Serious brain injury or lack of oxygen to the brain
∙ Brain tumors
∙ Infections of the brain such as meningitis or encephalitis
∙ Cerebral palsy
∙ Mental disabilities
∙ Seizures occurring within days after head injury
∙ Family history of epilepsy or fever-related seizures
∙ Lengthy fever-related (febrile) seizures
∙ Alcohol or drug abuse
Types of Seizures
Usually, they classify seizures into two types, primary generalized seizures and partial seizures.
Primary generalized seizures begin with a widespread electrical discharge that involves both sides of the brain at once. Hereditary factors are important in many of these seizures. Epilepsy in which the seizures begin from both sides of the brain at the same time is called primary generalized epilepsy. Primary generalized epilepsy is more likely to involve genetic factors than partial epilepsy, in which the seizures arise from a limited area of the brain.
Generalized tonic-clonic (grand mal) This type of seizure is characterized by sudden cries, a fall, rigidity and jerking of the muscles, shallow breathing, and bluish skin. Loss of bladder control is possible. The seizure usually lasts two to five minutes, and is followed by confusion, fatigue, and/or memory loss. It can be frightening to witness, especially for the first-time observer.
Partial seizures begin with an electrical discharge in one limited area of the brain. Some are related to head injury, brain infection, stroke, or tumor, but in most cases the cause is unknown. One question that is used to further classify partial seizures is whether consciousness (the ability to respond and remember) is "impaired" or "preserved." The difference may seem obvious, but there are actually many degrees of impairment or preservation of consciousness.
Partial seizures take place when abnormal electrical brain function occurs in one or more areas of one side of the brain. In about one-third of children with partial seizures, the child may experience an aura before the seizure occurs. A strange feeling, consisting of either visual changes, hearing abnormalities, or changes in the sense of smell.
For example, the words "partial" and "generalized" suggest that seizures either involve only part of the brain or are widespread. Epileptic seizures are triggered by abnormalities in the brain that cause a group of nerve cells in the cerebral cortex to become activated simultaneously, emitting sudden and excessive bursts of electrical energy that lead to seizures. Depending on the location in the brain where this electrical hyperactivity occurs, seizures have a wide range of effects on the sufferer, from brief moments of confusion to minor spasms to loss of consciousness. There are several more rare seizure types, such as atonic seizures and infantile spasms. Symptoms can vary from twitching or tightening of one group of muscles (such as jerking of an arm) in the case of simple partial seizures, to repeated staring spells and confusion (in absence seizures) to loss of consciousness and jerking of the whole body.
Atonic Seizures a person who has an atonic (or akinetic) seizure loses muscle tone. Sometimes it may affect only one part of the body so that, for instance, the jaw weakens and the head drops. At other times, the whole body may lose muscle tone, and the person can suddenly fall. A brief atonic episode is known as a drop attack.
Infantile spasms (West syndrome) are associated with brain development abnormalities, tuberous sclerosis, and perinatal insults to the brain. It affects infants between one month and one year old. It carries a poor prognosis such that only 5-10% of children with infantile spasms will develop normally to near normal function, while more than two-thirds will have severe deficits. The typical seizures are characterized by sudden flexor and extensor spasms of head, trunk, and extremities.
Absence (petit mal) is a type of seizure is most common in children. It is characterized by a blank stare lasting about half a minute; the person appears to be daydreaming. During this type of seizure, the individual is unaware of his or her surroundings.
During the seizure, the child's lips may become bluish and breathing may not be normal. The movements are often followed by a period of sleep or disorientation. The symptoms of a seizure may resemble other problems or medical conditions. Always consult your child's physician for a diagnosis.
Epilepsy and learning
Children with epilepsy have the same range of intelligence and abilities as other children. However, some children with epilepsy will develop learning difficulties. This is usually due to a coexisting condition, such as an underlying brain abnormality, or it might be related to the child’s frequent seizures. Sometimes the medication is a contributing factor as it may cause drowsiness or hyperactivity. If the child has the type of seizure characterized by a brief period of fixed staring, he or she may be missing parts of what the teacher is saying. It is important that the teacher observe and document these episodes and report them promptly to parents and to school nurses. When a learning difficulty is identified in a child, there are strategies available, both medical and educational, that can be implemented.
Epilepsy and Behavior
Behavioral disturbances can occur in any child, whether or not they have epilepsy, and it can be difficult for parents to know the cause. The factors that affect learning in a child with epilepsy may also affect behavior. In addition, low self-esteem can result from overprotection, lack of discipline or the child feeling different to other children. Parents may find that discussing the issue with teachers is helpful. Teachers or counselor may provide a gateway to additional support services.
Children with epilepsy must also deal with the psychological and social aspects of the condition. These include public misinterpretations and fear of seizures, uncertain occurrence, loss of self control during the seizure episode, and compliance with medications. To help children feel more confident about themselves and accept their epilepsy, the school can assist by providing epilepsy education programs for staff and students, including information on seizure recognition and first aid.
Vaccination Concerns
In young children, high fever from a vaccination can, in rare instances, trigger seizures, which are almost always temporary and have no serious consequences. Some controversy arose a few years ago over the possibility that the DTP (diphtheria-tetanus-pertussis) vaccine might trigger epilepsy or other neurologic disorders. Some experts suggest that children who have neurologic events following their DTP shot already have a preexisting impairment such as epilepsy, which is revealed but not caused by the vaccine. Children with existing epilepsy may be at risk for seizures two or three days after the vaccination. Such a temporary worsening of their condition does not appear to pose a danger to the child. Infants with suspected neurologic problems may have their vaccinations delayed until their neurologic situation is clarified, but not beyond their first birthday.
Diagnosis
Diagnosis is made by a doctor based on symptoms, physical signs, and results of tests such as an
electroencephalogram (EEG), computed tomography (CT or CATS scan), or magnetic resonance imaging (MRI). It is essential that the type of epilepsy and the type of seizures are both diagnosed properly. There are several major classifications of seizures, and most are associated with specific forms of the disorder. During the examination, the physician obtains a complete medical history of the child and family and asks when the seizures occurred. Seizures may be due to neurological problems and require further medical to follow up.
Treatment
Most types of epilepsy can be treated and totally or partially controlled through medication, diet and life style changes as well as surgery. Epilepsy may be treated with drug therapy, surgery, biofeedback, vagus nerve stimulation (VNS) or a ketogenic diet (low-carbohydrate diets). The wide range of antiepileptic drugs (AEDs) remains the foundation of treatment.
AEDs treat the symptoms of epilepsy (the seizures), rather than curing the underlying condition. The drugs act on the brain to prevent the seizures from starting by reducing the tendency of the brain cells to send excessive and confused electrical signals. Before any drug is prescribed, discuss potential benefits, side effects and risks with your doctor.
Surgery for epilepsy and seizures is a very complicated surgery performed by a specialized surgical team. The operation may remove the part of the brain where the seizures are occurring, or, sometimes, the surgery helps to stop the spread of the bad electrical currents through the brain. Surgery is not an option for everyone with seizures. Discuss this with your child’s physician for more information.
VNS, approved by the FDA in 1997, is designed to prevent seizures by sending regular, mild pulses of electrical energy to the brain via the vagus nerve. It requires minor surgery to implant a stimulator, which is about the size of a silver dollar. The stimulator is placed under the skin in the upper chest, like a pacemaker. The treatment appears to be effective for seizures that do not respond well to medications alone. The effectiveness of this treatment is about the same as drug therapy. VNS decrease seizure numbers by at least half in 40 to 50 percent of patients, but rarely eliminate all seizures. Almost all patients need to continue taking medications after the stimulator has been placed, although dosages can usually be decreased.
The ketogenic diet, which is very high in fat (90%), very low in carbohydrates, and low in protein, has been studied and debated for decades. It has proven to be helpful for many children with severe epilepsy that does not respond to AEDs. It is not clear why it works. Studies report significant reductions in seizures in up to 85% of children who are good candidates for the program. A 2001 study was conducted on children three to six years after they had initiated the diet. In the study, 27% were with seizure free or had experienced more than a 90% reduction in seizures. About 40% were either off medication or down to one. Only 10% of the children were still on the diet. Many children also report significant improvements in attention and social functioning one year after starting the diet.
Suggestions
Children who have epilepsy, you should wear a medical bracelet or necklace that identifies their disorder and lists any medications they take. Help prevent the seizures by following a healthy diet, getting adequate sleep, and keeping stress a minimum. Since fevers can trigger seizures, give them medication that lowers fever at the first sign of illness. If the seizures begin with an aura (feeling), get the child to safe place where they can lie down until the seizure passes. Also make sure those close to the child know what to do when having a seizure.
∙ Do not leave the seizure victim alone
∙ Anyone nearby should call 911. Children should be taken to an emergency room if:
∙ Any seizure lasts beyond two or three minutes.
∙ The patient has been injured
∙ The patient is diabetic.
∙ Parents, caregivers, or bystanders are at all uncertain.
Tips for Helping Children
Some of the following tips may help the child with epilepsy:
∙ Children should be treated as normally as possible by parents and siblings.
∙ Children should be assured that they will not die from epilepsy.
∙ Often children can be given the hope that they will outgrow the disorder.
∙ Most children will not have seizures triggered by sports or by any other ordinary activities that are enjoyable and healthy.
∙ As soon as they are old enough, children should be active participants in maintaining their drug regimens, which should be presented in as positive a light as possible.
Outcomes
According to one 2000 study, about 64% children with one seizure unrelated to fevers have another one, and nearly two-thirds who have a history of more than one seizure are likely to have more seizures. Researchers are trying to find ways of predicting which children have the best chances to become seizure free, and which ones will not. Studies suggest that the frequency of early seizures, not their total number or type, determines whether a child will develop intractable epilepsy.
In general, the long-term effects of seizures vary widely depending on the seizure's cause. Children with febrile seizures rarely have any long-term effects. In very rare cases, children experience severe fever related seizures known as complex febrile convulsions. In such cases, there is a risk for brain injury that may lead to temporal lobe epilepsy, but this is very small. Such seizures last more than 15 minutes, occur more than once within 24 hours, and may affect only one side of the body.
The long-term outlook for children with idiopathic epilepsy (epilepsy of unknown causes) is very favorable. One study reported that individuals were seizure free after 20 years. In addition, a 2000 study reported that they had a survival rate no different from children without these seizures.
Children whose epilepsy is a result of a specific condition (for example, a head injury or neurologic disorder) have higher mortality rates than the normal population, but their lower survival rates are most often due to the underlying condition not the epilepsy itself.
It is well recognized that persons with epilepsy are subject to greater mortality than the general population. This has been documented both by research studies and the statistics of life insurance companies. Their long-term survival rates are lower than average, however, if medications or surgery fail to stop the seizures. There is a very low risk for sudden death in individuals with epilepsy however; both type and frequency of seizures affect mortality.
The higher than average mortality rate is least if there have been no recent episodes, suggesting that the mortality risk is largely limited to individuals with ongoing seizures. Although the causes of such events are not fully known, experts suspect heart arrhythmias in many cases. There is some evidence, in fact, that a malfunction in the autonomic nervous system (which controls heart rate) may be responsible for some of epilepsy deaths. Some researchers believe that temporal lobe surgery in appropriate patients may reduce the risk. Drugs that block arrhythmias may also be helpful in reducing this risk.
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