Seizures

Dear Lisa,

My little toddler has just recently had a seizure due to an elevated fever. He is 27 months old. Now I am beginning to wonder if he has epilepsy due to several reasons. Number one is...for several months he will just stare with a blank look in his eyes (as if he is really thinking about something) when we try to talk to him he acts as if we are not speaking to him at all. Then in a minute or so he will just begin to act like himself again. He also has just now started saying MaMa and DaDa..he is only able to say one or two more words...not very clearly though...however, he is extremely intelligent...as he knows exactly what you are saying to him and he has ways of letting you know what he wants...but he will not talk. Now that he has had this seizure due to a high fever from an ear infection...I am concerned that he may have been having seizures all along.. Please tell me if the symptoms I have described seem to be seizure related.....I love him so very much....

“Son with Staring Spells”

Dear “Son with Staring Spells’,

Epilepsy (also known as a seizure disorder) is one of the three most common neurologic disorders seen in the pediatric population.(1) Epilepsy is a chronic disorder of recurrent unprovoked seizures. A seizure is defined as a paradoxical nervous system event that is caused by an abnormal electrical discharge and associated with a change in usual functioning.(1} Seizures tend to occur more often in both the elderly and the very young and many Epileptic syndromes do present in childhood.

The typical manifestations of a seizure include twitching of the extremities, fluttering of the eyes, muscle rigidity or loss of muscle tone followed by a period of weakness. There are different types of seizures, some of them having a more subtle presentation. A simple partial seizure may present with something as mild as hand twitching and an Absence seizure can occur and appear as if a child is daydreaming.

There are triggers or conditions that can cause a seizure to occur. These triggers include; fever, injury, infection, sleep deprivation or use of elicit drugs.(1) The trigger itself can be quite serious and needs to be addressed as well as the seizure itself. It has been determined that one in eleven people will experience a seizure sometime in their lifetime.(2) Therefore, not everyone who has a seizure is considered to have Epilepsy. A diagnosis of Epilepsy is only made when a child has two or more unprovoked seizures or one unprovoked seizure with an abnormal EEG.(1)

Unprovoked means the seizure is not caused by a trigger. Therefore children who experience a seizure caused by a trigger are not considered to have Epilepsy. A seizure associated with a fever or a Febrile Seizure is considered a provoked seizure and is different from Epilepsy.

A Febrile Seizure is defined as a seizure that is associated with a fever in a child who is over 6 months old and free from a central nervous system infection or electrolyte imbalance. Febrile seizures more commonly occur in children between the ages of 6 months and 6 years old, with the average age of occurrence being 18 months old.

Children at risk for developing Febrile Seizures include those with a first or second degree relative with a history of Febrile Seizures, children who had a neonatal nursery stay for more than 30 days, children with a developmental delay and those attending daycare.(3) Although, it is possible for any child to develop a Febrile Seizure.

Witnessing a Febrile Seizure is a very scary experience, especially if it is your child having the seizure. Thirty three percent of children who have a Febrile Seizure will experience a second one and 10% will have three or more. (4) Children who experience their first Febrile Seizure before 18 months old are more likely to have recurrences.(1) Many doctors recommend control of future fevers with Tylenol every 4 hours or Ibuprofen every 6 hours, but there is limited evidence that these measures prevent a Febrile Seizure from occurring.(1)

When a child experiences a Febrile Seizure, this does not mean he will develop a seizure disorder later in life. You should be relieved to know that researchers on the Perinatal Collaborative Study noted that young children with febrile seizures do not go on to have chronic seizures.(5)

Even though your son’s Febrile Seizure does not constitute a seizure disorder such as Epilepsy, his staring spells are a concern. One type of generalized seizure, an Absence Seizure can present as a staring spell in children. The usual age of occurrence of Absence seizures is between 4 and 25 years old. During an Absence seizure a child experiences a brief loss of environmental awareness. Typically these staring spells only last a few seconds. Many times they are accompanied by eye fluttering or other manifestations such as turning of the head/eyes or humming.(6) Unlike other types of seizure activity, postictal symptoms such as weakness or confusion do not occur after an Absence Seizure.

In order to determine if these staring spells represent true seizure activity, an evaluation by a Pediatric Neurologist should be performed. A detailed description of the events is needed in order for the Doctor to diagnose a seizure disorder or determine if the episodes are due to another cause.(1) In addition to the evaluation, bloodwork and diagnostic testing including an EEG are typically part of the work-up.

In order to provide a thorough description of your son’s spells , it would be a good idea to keep a diary of the events. The diary should include the time of day, duration of the spell, any associated symptoms, your son’s activity before and after the episode, whether there is a change in color or breathing pattern and whether or not there are vocalizations during the event.(1) Other information such as your son’s sleep and family history will also need to be related to the doctor in order to make the presentation complete. It would be helpful if the doctor had a video recording of the event so that he can witness the episode firsthand.

Staring spells could also be a sign of a developmental delay. Having a developmental delay does not mean that a child is not intelligent. In some cases there may be a deficit in a specific area such as expressive language or hearing that may prevent a child from attaining his developmental milestones. One of the risk factors for a Febrile Seizure is a developmental delay and from the description of your son’s speech, it sounds like he may have a delay in his speech development.

Typically by the time a toddler is 25 months old he should be able to express up to 270 words with an average of 75 words spoken per hour during free play. At this age a child should use phrases in their speech by putting two words together such as, “Give me” or “milk please”. (7) Since your son is 27 months old and saying only 4 single words, this puts him in the category of a child who has a delay in speech development. It would be important to discuss this with your son’s Pediatrician.

Your Pediatrician can refer you to a Speech Therapist of Early Intervention Program in your area for an evaluation. Addressing this issue should be done at this time because early treatment is the key to promoting childhood development. Early Intervention Programs do have a cut off age which means your son may not be eligible for these services if you wait until he is older.

If your son is diagnosed with a speech delay it is also important to have other areas of childhood development evaluated. A comprehensive evaluation is necessary because in some cases a language delay in childhood can be a presenting symptom of another problem.(8) A child’s coordination, sensory skills, neurological status, perceptual-motor function, neurologic status and hearing are additional areas that should be assessed. An initial screening at the Pediatrician’s office is usually the first step and in some cases a referral to a Neurodevelopmental specialist may be necessary.

Your son is very luck to have a mother that is so concerned about him and loves him so much. By approaching these issues one day at a time you will be able to get all of the information that you need. I wish you and your son well.

If you are interested in reading other Pediatric Advice Stories about topics discussed:

Speech Delay

Infant with Back Arching

References:
(1)Wolf S McGoldrick P. Recognition and Management of Pediatric Seizures. Pediatric Annals.2006.35(5):332-344.
(2)Resnick TJ. Epilepsy 101: practical points for pediatricians. Presented at: Miami Children’s Hospital’s 41st Annual Pediatric Postgraduate Course: “Perspectives in Pediatric”:February 6-9,2006; Miami Beach, Fla.
(3)Camfield P, Camfield C, Gordon K. Antecedents and risk factors for febrile seizures. Febrile Seizures. In: Baram TZ, Shinnar S (eds) Febrile Seizure. Philadelphia, PA: Elsevier; 2002:27-35.
(4)Shinnar S. Pellock JM. Update on the epidemiology and prognosis of pediatric epilepsy. J Child Neurol. 2002;17(Suppl 1):S1-S14.
(5) Zacharyczuk C. New Data lead to better treatment for children with seizures. Infectious Diseases in Children. 2006. February:47.
(6) Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:647.
(7)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:933-955.
(8)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:2074.


Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Advice For Parents About Childhood Health Conditions