Discussing epilepsy's initial signs and treatments in the pediatric population

In this Contemporary Pediatrics interview, William Gallentine, DO, clinical professor of neurology, interim chief, Pediatric Neurology, Stanford Medicine Children's Health, discusses what to look for when suspecting epilepsy in children, who to refer to, and how to break down seizures to worried parents.

Interview transcript (edited for clarity):

Contemporary Pediatrics:

What signs can the general pediatrician look for suspecting epilepsy?

William Gallentine, DO:

So seizures really are behaviors that occur whenever we have abnormal electrical discharges occurring within the brain. They can occur within many areas and depending on where those seizures are coming from, oftentimes, the behaviors that you can see in association with those can vary quite dramatically. Because of that, seizures can have a varied appearance in terms of how they may look.

The appearance of them, sometimes the child can be confused, and not behaving appropriately with repetitive type of movements on one side of the body. Other times, they actually may be more what people more traditionally think of as kind of generalized convulsions where the entire body may stiff and, and shake. Those are things that seizures that are more readily recognized by providers, and are not quite as subtle, and the ones that oftentimes quickly become presented to emergency departments, and brought in as acute level of care. So depending upon the nature of the seizure, oftentimes they may be determined to be seizures easier.

A hallmark of things that would kind of highlight them being seizures, would be seizures oftentimes look the same. So they have the same appearance when they occur. If they are occurring in the same area of the brain, that same area of the brain is involved, oftentimes, you'll have this appearance, that will look the same over and over again. So if you're having repetitive behaviors, that kind of look the same for short periods of time, that's kind of the hallmark of seizures.

The other things that you can also kind of look to are the events that occur out of sleep, that are also repetitive, can oftentimes be a clue that this could be something that's potentially related to epilepsy.

Contemporary Pediatrics:

Who should a child be seeing once epilepsy is suspected after a primary visit?

Gallentine:

Making sure that they're seeing an epilepsy provider, someone with it with expertise in that area, and that certainly could be a child neurologist or an epilepsy specialist. The majority of children that we take care of seizures can be well controlled with our typical anti-seizure medications, and really can go about their normal lives and do all the things that we wished for them to do.

But there is a smaller subset of patients that make up about 20% or 30% of patients with epilepsy, that the seizures become very difficult to control and are resistant to the medications. In those scenarios, even if they are seeing a child neurologist, if they haven't been seen at a tertiary medical center with expertise in epilepsy, it's really important to advocate for the patient being evaluated in a program like that, because there are different types of therapies, there are different approaches in the centers that we'll be taking will be very aggressive in terms of trying to get the seizures under better control.

That may be with further medications, but oftentimes that may be going a different route with our treatments. That may be including surgical interventions, where we're actually trying to render a patient seizure-free by doing a specific surgery to eliminate epileptic focus, that may actually be offering dietary therapies where we're using specific things like ketogenic diet to try to help control seizures, or it could even be implanting nerve stimulators, where were actually putting in stimulators, either on the periphery, or actually even into the brain that may help decrease the frequency and improve overall seizures.

All this is extraordinarily important, because we know that the longer children go with very difficult to control seizures, the worse their outcomes ultimately are. This could have an impact on their overall cognition, and their overall long term potential within their lives to do the things that they ultimately want to do.

Contemporary Pediatrics:

What can the general pediatrician do during initial visits to not only help the child, but also reassure the parents?

Gallentine:

The big thing is one, recognize that this is a very scary situation. These are some of the most scary situations that parents can go through and so sort of recognizing that our property yes, this can be very scary, but the reality of it is, that the majority of children who are having a seizure, once the seizure is over, the emergency is over. In the acute period, and that period with the seizures occur, really the sole job is this kind of support the child, make sure that the child is safe. In that scenario, [it] is recommend basic seizure first aid. One, look at your watch so you know how long the seizure is lasting, and then two, just making sure the patient is safe.

Most seizures in most individuals are only going to last 1 to 2 minutes in duration and following that, like I said, the emergency is over. Where the bigger problem comes, is when the seizure lasts more than 5 minutes, then the likelihood of that seizure ending on its own without medical intervention really begins to drop off. Oftentimes, you're going to require a medication to actually get that to seizure to stop. That's a scenario where one, activating 911, if the seizure is clearly going to be a prolonged seizure, and number two, hopefully those patients will have rescue medications. Medications that have been either provided by their primary care doctor, at the emergency department, or if they've already seen a neurologist in that particular setting, and administering a rescue medication at that 5-minute mark, really trying to avoid prolonged seizures.

Seizures that last more than 30 minutes, which then potentially result in injury to the brain. Usually, a lot of the time is spent on that initial visit with a first time or second time seizure patient. One, trying to have the parents understand kind of what's an emergency and what is not. And realizing that in most circumstances, the seizures are going to be brief. They're going to get through them, and really, we just want to make sure that things are safe. We don't want [the child] putting things into their mouths, we want to roll them in a rescue position so that they're safe. But really, just getting them through that and then supporting them. So that's kind of the acute portion of that. And then the next question that's always on the mind, of all the families was 'why is this happening?' And in that situation, it's going to come down to their evaluation in terms of what's the underlying cause. In most circumstances that evaluation is going to be led by the neurologist. So getting them in with those appointments, getting them in to see the neurologist and kind of move forward with those evaluations can be very helpful in expediting those things.