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Introduction

Seizures are caused by abnormal electrical discharges in the brain. Seizures can involve both the body (convulsions) and mind (altered mental status) or only parts of the body. Seizures are life-threatening when a condition known as status-epilepticus occurs, meaning the seizure will not subside (1). Seizures can cause changes in behavior, mood, or feelings.

A seizure can be a frightening experience for a parent or child. The nurse plays a critical role when seizures in children occur by imparting knowledge about the disease, teaching self-management skills, and discussing treatment options. Seizures in children are common, as approximately 4-5% will experience one at some point during their childhood. About 1% of children are diagnosed with epilepsy, and 1 in 26 people develop this neurological condition during their lifetime (2).   

It is crucial to understand what constitutes a seizure before learning about seizure management. We will continue this discussion on how a seizure is classified in order to evaluate how to treat seizures in children.  

Epidemiology  

Epilepsy is the most common neurologic condition in children with around 470,000 children and teens being affected. Epilepsy, or seizure disorders, can result from a variety of causes, including genetic conditions, injuries to the brain, birth trauma, stroke, and brain tumors. Sometimes the cause behind a seizure disorder remains unknown (8).   

Since epilepsy can affect anyone and may not have an identifiable cause, the risk factors are difficult to identify. We do know that children are at an increased risk of developing a seizure disorder if they have relatives with epilepsy, a history of a traumatic brain injury or brain infection, or other existing neurological conditions (7,8).   

The impact of a seizure disorder on a child’s life can vary greatly depending on the type and severity of seizures experienced, as well as a child’s response to treatment methods. Some seizures are easily managed, and children may even outgrow them, while others may significantly impact functioning for the rest of a child’s life (7, 8).   

Children who suffer from frequent or debilitating seizures may also deal with complications like fear of seizures, physical injuries that occur during seizures, sleep disruption, poor concentration and school performance, and feeling different from peers or having a negative impact on self-esteem. It is also common for children with seizure disorders to have comorbid diagnoses of anxiety, depression, intellectual disabilities, or neurocognitive disorders like ADHD or autism (7, 8).   

Children with seizure disorders are more likely than their peers to miss school due to symptoms or attending health-related appointments or diagnostic testing. This has both a social impact and academic impact on the child, as well as a financial impact on the family, with most families spending between $1,000-$10,000 annually on costs related to the diagnosis. These children need increased care coordination and specialized services in childhood and into adulthood and data shows many children do not receive the resources they need. These gaps in care also disproportionately affect children who are of minority ethnicities or lower socioeconomic status (9).   

Pathophysiology and Categorization of Seizures 

All seizures are caused by some form of electrical or chemical changes in the brain, but where in the brain the seizure starts and if and how it spreads, will determine the type of seizure that is occurring. In general, seizures can be classified as either general, involving the entire brain, or focal, starting in one area of the brain.   

Focal Seizures 

Focal seizures can be aware or impaired awareness in nature. A Focal Onset Aware Seizure involves uncontrolled movements or sensory changes (such as smells or tastes) that the child is aware of. Despite being aware of the change, the client is unable to respond to others or control their movements. These seizures usually last anywhere from a few seconds to 2 minutes. Sometimes children will have these sensations prior to going into a more generalized seizure; in this case, the focal onset aware seizure may be referred to as an aura. Alternatively, a Focal Impaired Awareness Seizure causes children to be confused and unaware of their surroundings, repetitive movements, screaming, and fear which may occur while sleeping. These seizures last 1-2 minutes. Both types of focal seizures begin in one part of the brain and the affected area has an impact on the types of symptoms exhibited (8).   

Generalized Seizures 

Generalized seizures include a few different subtypes as well, all involving the whole brain. Absence Seizures involve reduced consciousness or awareness, sometimes mistaken for daydreaming, lasting no more than 30 seconds. Children may stare blankly, blink rapidly, or have facial twitching, and then return to normal with no awareness of what just occurred (8).   

Atonic and Tonic Seizures 

Atonic and tonic seizures occur when a child suddenly collapses from a lack of muscle tone (atonic) or generalized stiffening (tonic). These children may be limp and unresponsive for up to a minute and will regain consciousness but feel sleepy. Due to the sudden collapse, these children are at an increased risk from head injuries and other injuries from falling (8).   

Generalized Tonic Clonic Seizures 

Generalized tonic clonic seizures (or convulsive seizures) are the most common type and also the most readily recognized as a seizure. These are characterized by loss of consciousness, stiffening, and rhythmic jerking movements of the arms and legs. Children may have blue discoloration, drooling or foaming at the mouth, loss of bowel or bladder control, and bite their tongue or cheek. These seizures will typically last 1-3 minutes, and the client will often be confused, irritable, and need to sleep afterwards (8).   

Myoclonic Seizures 

Myoclonic seizures are characterized by sudden jerking movements of muscle groups, often in the upper body. Clients are conscious and aware during these seizures, but unable to stop the movements which may result in falls. These occur quickly and are usually over in just a few seconds (8).   

The types of seizure, affected area of the brain, age of onset, EEG results, and other criteria are all combined to determine which specific epilepsy syndrome a child has. There are currently over 25 unique epilepsy syndromes and presentation, and management will vary depending on the type diagnosed (8).   

Diagnosis   

Comprehensive evaluation is needed for a diagnosis of epilepsy. A thorough history of present symptoms as well as an in-depth family history is needed.   

A thorough physical and neurological exam is needed to rule out any additional symptoms that might indicate a cause or comorbid condition contributing to the seizures. Of particular importance are (10: 

• Vital signs, particularly assessing for fever 
• Trauma, bleeding, or bruising that might indicate a traumatic injury 
• Skin hyper or hypopigmentation, birthmarks, or hemangiomas that might indicate vascular disorders 
• An eye exam for abnormalities that might indicate optic or brain tumors 
• Growth delays or limb asymmetries that might indicate perinatal injury 

Additional testing such as blood testing for glucose levels, electrolytes, and bacterial cultures, or spinal tap to assess for infection, imaging such as MRI or CT scan to assess for structural changes in the brain, and electroencephalogram (EEG) to monitor brain electrical activity over a period of time may be needed (7).   

Typically, a diagnosis of epilepsy will be made if a child has at least 2 seizures, with >24 hours in between and all other causes or diagnoses have been ruled out (8).   

Treatment 

Treatment of seizure disorders depends on the epilepsy syndrome diagnosed, the age of the child, and the severity of symptoms.  Pharmacologic therapy consist of medications to raise the seizure threshold and reduce or prevent seizures, and nonpharmacological treatments. Some medications used to treat seizures are indicated for certain types of seizures. 

Pharmacologic 

Antiepileptic drugs work by reducing the responsiveness of neurons to sudden onset of high frequency impulses, reducing seizures but not necessarily abnormal brain waves. Different medications target different types of seizures and have different uses. Common choices include carbamazepine, phenytoin, valproic acid, phenobarbital, clonazepam, gabapentin, lamotrigine, topiramate, and oxcarbazepine (12).   

These medications come in a variety of formulations and dosing schedules to meet the unique needs of clients of various ages. Common adverse effects to monitor include nausea, blurred vision, dizziness, sedation, weight gain, and brain fog. Black box warnings for hepatotoxicity or severe rashes are common (12).    

Nonpharmacologic 

Non-pharmacological treatments may be considered for children whose seizures are not well controlled even with medications, or for those who wish to add additional management. Options consist of surgery, neuro-stimulation, and diet. The goal of surgery is to stop the seizure activity (resection or ablation) or to prevent the spread of disabling seizures.  

Neuro-stimulation via the vagus nerve is another option for patients who are not candidates for surgery. The vagus nerve stimulator (VNS) is a small device surgically implanted under the left clavicle with a lead attached from the device extended to the left vagus nerve. The electrical stimulation is programmed wirelessly and provides ongoing intermittent stimulation. This can result in decreased seizure frequency and/or length. The device can provide on-demand stimulation to stop or shorten a breakthrough seizure with use of a magnet when applied to the VNS implant through the clothes.   

Diet therapy can reduce seizures in patients with epilepsy. The classic epilepsy diet is ketogenic, high fat and low carbohydrate, which forces the body into a state of ketosis which has been shown to reduce seizure activity. Liquid formula is available for children who are not yet eating solids. About 50-60% experience seizure reduction, and up to 33% experience a 90% reduction. More than 10% are seizure-free (5). The diet is not difficult to learn but requires a firm commitment from families and a complex change in dietary behaviors. Close monitoring of growth, including height and weight, as well as supplementation of vitamins is necessary. Potential complications include hypoglycemia, constipation, kidney stones, and poor weight gain (12).   

Complications   

Acute complications of seizures are mostly related to injuries that may be sustained during seizure activity, including falls or head injuries, choking or aspiration of food or liquids, car or bicycle accidents, and drowning.   

Repeated or uncontrolled seizures may cause blood flow issues to the brain and long-term effects like learning disabilities and permanent brain damage. The prevalence of attention deficit hyperactivity disorder (ADHD) among children with epilepsy is 20-50%, compared to the 7-9% prevalence of the general pediatric population. Thirty-two percent of children with epilepsy have a learning disability. Autism and epilepsy have a reciprocal relationship, as there is both an increased risk of autism among children with epilepsy (6.3%), and an increased risk of epilepsy in children with autism (20-30%).   

Status Epilepticus is a seizure lasting longer than 5 minutes or experiencing more than 1 seizure within that 5-minute period without a return to normal consciousness during that time. It is rare, but more common in children and is a medical emergency due to the risk for permanent brain damage and death. Severe infection with fever, such as encephalitis or meningitis, is the most common cause in children, though there are other causes such as hypoglycemia, stroke, alcohol intoxication, and poorly controlled epilepsy (11).   

Sudden Unexpected Death in Epilepsy (SUDEP) is a very rare but tragic complication and we do not have a clear understanding of its cause. This complication occurs in only about 1 in every 3,000 children with epilepsy, more often in non-white children. It is possible that irregular heartbeat or respiratory arrest during a seizure may cause death during or immediately after a seizure.  

SUDEP is a greater risk for clients who: 

• Experience frequent or uncontrolled seizures 
• Experience tonic clonic seizures 
• Frequently miss doses of their seizure medication 
• Experience seizures at night 
• Have comorbid developmental disabilities like cerebral palsy or autism 

Seizure Management: The Nurse’s Role   

Acute Management: Seizures in the Hospital Setting 

When caring for children in the hospital who are experiencing seizures, whether for the first time, or with a known seizure disorder, it is important for the nurse to note specific details and assessments during and after the seizure to create a comprehensive picture and most effective plan of care.   

Details to consider include timing (time of seizure onset), what the client was doing at the time, and how long the seizure lasts. The nurse also consider the client’s behavior before and at the start of the seizure, any aura, change in facial expression, cry or sound, posturing, movements, muscle tone of body, tonic or clonic movements, facial expression, color changes in the skin, and any biting of the tongue or inner cheek. Additional assessments include checking for foaming at the mouth, respiratory effort, and incontinence. The period after the seizure subsides is known as the postictal period and clients should be observed for state of consciousness, orientation, motor ability, sensation, speech, mood, and duration of the postictal period (12).   

Ordered benzodiazepines may be given rectally to stop a seizure that is lasting too long and clients who are cyanotic may be given supplemental oxygen or airway support. Clients should not be moved, and their environment should be made safe. When a seizure is over, they should be assessed for any injuries sustained (12).   

At Home Management: Education to Parents/Guardians 

Seizure management also includes empowering families by teaching about seizures, self-care tips, first aid, medication, and diet. When teaching parents about seizures and self-care tips, there are several points that the nurse should review:  

• Epilepsy can be very unpredictable  
• The classification of seizures and possible symptoms  
• Breakthrough seizures can occur despite adhering to the treatment plan  
• Know what to do when a breakthrough seizure occurs (follow a seizure action plan)  
• Try not to become overprotective of your child and understand that age-appropriate discipline will not cause a seizure  
• It is important to spend time with the rest of your family  
• Connect with other parents/guardians of children with epilepsy  
• In order to advocate for your child, learn about federally mandated protection and assistance offered by your state 

When teaching about first aid for a seizure, it is important to distinguish between a convulsive and non-convulsive seizure. For a convulsive seizure:  

• Stay calm and stay with the child  
• Turn the child onto their side  
• Make the child as comfortable as possible  
• Loosen any tight-fitting clothing  
• Do not put anything in their mouth  
• Do not try to stop the convulsions or restrain the child  
• Note the time of the seizure  
• Call 911 for any seizure lasting more than 5 minutes or if the child is injured during the seizure  

When the seizure is non-convulsive:  

• Stay calm and stay with the child  
• Note the time of the seizure  
• Do not grab or hold the child  
• Explain to others what is occurring  
• Protect the child from any hazards  

When the child is alert, provide reassurance. Use simple language and be supportive. The nurse should also instruct the family on the following safety precautions. 

• Ensure the child avoids tub baths  
• Ensure the bathroom door is not locked 
• Do not let the child swim unless there is constant supervision  
• Ensure the child wears a helmet when bike riding  
• Ensure the child (of age) does not cook over an open stove  
• Ensure teenagers with uncontrolled seizures do not drive  

After you have empowered your families with knowledge and education, you should stress the importance of following a seizure action plan.    

Seizure Action Plan 

The seizure action plan is a tool that can be used by families and schools to help record information about the child’s seizures and guide actions when seizures occur. The plan should include the child’s name, date of birth, parent or guardian’s phone number, emergency contact, and treating physician. On the seizure action plan, there is a place to document the seizure type, seizure length, frequency, description, seizure triggers or warning signs, and the child’s response after a seizure. There is also a section for basic first aid, emergency response, treatment protocol, special considerations, and precautions.     

Case Study   

Now it is time to put everything that has been learned together and explore a case study.  

You are working in the emergency room when a 14-month-old child presents with his parents after suddenly losing consciousness in his highchair and having repetitive jerking movements of his arms and legs. The parents reports the incident lasted about 90 seconds, after which he seemed to return to consciousness, the movements stopped, and he began crying. Now he is very irritable and sleepy. The parents report he has never done this before.    

• What other information would be useful to know?   

• What testing do you think might be needed for this client?   

• What education would you provide for the parents?  

Conclusion  

A nurse’s role is vital when seizures in children occur. They must empower families with the necessary tools on how to live safely with seizures. Seizures can be unpredictable and frightening. Families need the expertise of nurses to assist them when dealing with this dilemma. It is important for the nurse to educate the family on what a seizure entails, treatments and therapy, first aid, seizure action plans, tips for coping, and provide support and resources. The nurse has a unique role in equipping families with what they need to survive a seizure.  

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