The approach to a child who has experienced a first unprovoked generalized tonic-clonic seizure is challenging and at the same time controversial.
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How to establish the diagnosis, ways and means of investigation and whether treatment is appropriate, are different aspects of this subject. The approach to a child who has experienced a first unprovoked generalized tonoclonic seizure is an important endeavour in daily clinical pediatric neurology practice.
If occurrence of an ictal event is established, the main question is whether treatment by Anti Epileptic Drugs AED should be initiated or not? The main reason for prescribing AED is to prevent further seizure. Thus such therapy is justified when there is reasonable chance seizure will recur. Deciding to initiate treatment requires balancing the risk of drug side effects against the psychosocial consequences of future convulsions.
Knowing that treatment does not ensure that seizure will not recur and that it merely lowers the probability of recurrence, it behooves us to think twice about initiating AED therapy.
A seizure is defined as abnormal paroxysmal neuronal discharge which is clinically manifested by motor, sensory, autonomic or behavioral disturbances 1. We hypothesize that ictal event is secondary to an imbalance between excitatory and inhibitory neurotransmitter activities in the brain. A provoked seizure is characterized by a specific trigger such as fever, central nervous system infection, intoxication or head injury. In these situations, it is definitely indicated to treat the seizure immediately along with addressing the triggering cause s.
On the contrary, unprovoked seizure is not associated with an obvious precipitating cause and may be related to epilepsy. Population-based studies of the incidence of first unprovoked seizure suggest that there are between 25, and 40, children per year in the United State who experience a first unprovoked seizure 2 - 6. Until recently, it was common practice for practitioners to prescribe a long duration of daily antiepileptic drug AED therapy after a child or adolescent experienced a single seizure of any type.
The rationale for this practice was the belief that all seizures were likely to recur and that seizure could be detrimental, causing brain insult. Also, it was thought that if any recurrence were to take place, this would lead to progressively more seizures.
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It was also assumed that AEDs were safe, having few side effects and were effective in prevention of seizure recurrence 2. These assumptions have undergone significant change over the past two decades, leading to a more optimistic view about the nature of seizure and a more conservative approach to the use of treatment 2. Recognition of different settings in which an unprovoked seizure occurs and identification of risk factors for recurrence helps us define the appropriate management.
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After a first unprovoked seizure, the decision regarding starting antiepileptic drug AED therapy, should be made on the basis of balancing the risk of side effects of AED versus seizure recurrence 1. Neonatal seizures are not considered part of this subject. Many children are seen by a physician after a first unprovoked generalize tonic-clonic seizure, a few after a first complex partial seizure, but almost none after a single absence or myoclonic seizure 7.
When a child presents after a single unprovoked seizure, the question which is immediately raised is will it happen again? Beregr and Shennar in their meta-analysis of the recurrence risk after a first seizure concluded that overall about 40 percent will have another seizure 7. Animal studies on kindling, which is an experimental technique for creating epilepsy by a series of subclinical electrical stimulations of the temporal lobe, induces progressive intensification of electrographic and behavioral seizures 9 - Also we have evidence from animal studies that prolonged or repeated convulsions under special situations can induce neuronal damage and predispose to epilepsy In affirmation of these evidences, recent animal research showed that prolonged convulsions, occurring during critical periods of brain development may alter neuronal activity and circuitry which predispose to future epilepsy 2 , 13 - We do not know how relevant animal studies are to seizure in human beings and at this point we are reluctant and skeptical in expanding the results of animal models to our daily clinical practice 2 , At the same time clinical evidence in pediatric neurology indicates that even prolonged seizure seldom causes clinically discernible brain injury unless associated with an acute neurologic insult The main reason for initiating treatment is concern for the risk of physical injury or death from a subsequent seizure, Serious injury from a seizure in a child is a rare event, which may occur after a fall associated with loss of consciousness.
To reduce that risk, restrictions are recommended that would apply to any young child, such as bicycling on a sidewalk rather than the street and always with a helmet and swimming only with a buddy 2. Showering rather than bathing is recommended for children and adolescents, unless they are supervised. Sudden unexpected death in children with epilepsy is, fortunately, very uncommon. When death occurs in epileptic children, it is nearly always related to an underlying neurologic or cardiac problem rather than epilepsy 2 , 12 - One-population-based study found that the risk of death in those with childhood-onset epilepsy is the same as that for the general population of children without significant neurologic disorder 2 , So far, no studies have been found that examined whether treating a child after a first unprovoked seizure would decrease the likelihood of either subsequent significant injury or sudden death.
A child who is taking medication for long duration is perceived to have a long standing illness by the child, family and school. Additionally, chronic treatment for seizure prevention is a burden for the family and may affect the ability to obtain health insurance.
Issues in teenagers become more complicated as concerns about driving license and teratogenicity come into play 2. The essential question that is raised when we face a child who allegedly experienced a first unprovoked generalized tonoclonic convulsion is: was the event a seizure?
On many occasions the first challenge is differentiating between a true seizure and seizure mimickers. Syncope, breath holding spells, tics and other movement disorders and night terrors are a few examples.
Evaluation of First Nonfebrile Seizures - American Family Physician
Careful description of events by a reliable person is of great value. Precipitating events, warning symptoms, duration, semiology of seizure and description of the postictal period are crucial aids in the characterization of an event 1. Taking into consideration the possibility that the event was not the first one is as significant as identifying a true seizure from others paroxysmal phenomena.
With careful questioning, retrospective recognition of a previous nonconvulsive or convulsive event is possible.
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Having this information may change the approach because a child who has had at least two unprovoked seizures is perceived as epileptic. If this is the case, and depending on successful classification of the epilepsy syndrome, the decision to treat or not to treat may be less controversial. Pneumococcal vaccination in Australian children: divergent outcomes October Siv Kvernmo October ICD and gender incongruence of childhood: a rethink is needed October Antenatal screening for cytomegalovirus infection: to know the chance, the chance to know October Paediatric melanoma: clinical update, genetic basis, and advances in diagnosis September Prophylactic use of probiotics for gastrointestinal disorders in children September Time to rethink pre-emptive interventions for infants with early signs of autism spectrum disorder September High flow nasal cannula—just expensive paracetamol?
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In: Harrison's Principles of Internal Medicine. New York, N. Accessed July 17, Verrotti A, et al. Neuropsychological impairment in childhood absence epilepsy: Review of the literature. Journal of the Neurological Sciences. The epilepsies and seizures: Hope through research. National Institute of Neurological Disorders and Stroke.
Accessed July 14, Brigo F, et al. Ethosuximide, sodium valproate or lamotrigine for absence seizures in children and adolescents. Cochrane Database of Systematic Reviews. Schachter SC. Antiseizure drugs: Mechanism of action, pharmacology, and adverse effects. Crepeau AZ, et al. Management of adult onset seizures. Mayo Clinic Proceedings. Kotagal S expert opinion.
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