Pediatric Primary Care (118 page)

e.  May see lip smacking, chewing, eye fluttering.

4.  Myoclonic.

a.  Brief contraction of a muscle group.

b.  Can drop objects.

c.  Recovery is immediate and often maintains consciousness.

5.  Infantile spasms.

a.  Clusters of seizures involving flexion jerk of the neck, trunk, and extremities.

b.  Range from subtle head drop or shoulder shrug to more violent action.

c.  Decreased responsiveness may follow spasms.

d.  Spasms are brief, lasting just a few seconds.

E.  Physical findings.

1.  Seizure rare to happen in office to observe, can have family video episodes.

2.  May be “normal” between seizures.

3.  Low-grade fever, up to 101°F may occur after seizure.

4.  Injuries possible, especially with atonic seizures.

F.  Diagnostic tests.

1.  EEG in awake and sleep states.

2.  MRI if focal spike on EEG or abnormal neuro exam.

3.  May do CMP, CBC if concerned abnormalities might be a cause.

4.  EKG for concern for cardiac disorder (syncope).

5.  Prolonged EEG to catch episodes if warranted.

G.  Differential diagnosis.

H.  Treatment.

1.  Anticonvulsant medication.

a.  Absence seizures–ethosuximide (Zarontin), lamotrrgine (Lamictal), divalproex (Depakote).

b.  Generalized–divalproex (Depakote), lamotrigine (Lamictal), topiramate (Topamax), levetiracetam (Keppra), felbamate (Felbatol), zonisamide (Zonegran).

c.  Infantile spasms–ACTH, topiramate (Topamax), Vigabitrin (Sabril).

2.  70% of patients with epilepsy will gain seizure freedom with medications.

3.  Vagal nerve stimulator or ketogenic diet for intractable seizures.

I.  Follow up.

1.  Medication management, anticonvulsant therapeutic levels, and possible need for CMP, liver functions, CBC for some medications.

2.  Medication side effects.

3.  Continued seizures.

J.  Complications.

1.  High risk for depression in epilepsy patients.

2.  Medication side effects.

3.  Developmental delay.

4.  Anxiety, intellectual underachievement.

K.  Education.

1.  Seizure/epilepsy etiology and prognosis.

2.  Seizure safety.

3.  Psychosocial comorbidities.

4.  Medication management and possible side effects.

5.  Reevaluation parameters.

XII.  PARTIAL SEIZURES

A.  Seizure, electrical disturbance, arising from one area of the brain; consciousness may or may not be preserved.  Can spread to become generalized.

B.  Etiology.

1.  Idiopathic (most common in children).

2.  Brain injury/trauma.

3.  Developmental brain abnormality.

4.  Tumors (rare).

5.  Infectious or hypoxic injuries.

C.  Occurrence.

1.  Most common type of seizure experienced by people with epilepsy.

2.  Risk factors–developmental and brain abnormalities.

D.  Clinical manifestations.

1.  Depends on which part and how much of the brain is affected.

2.  Virtually any movement, sensory, or emotional symptom can occur.

3.  Simple partial.

a.  No loss of consciousness.

b.  Motor signs.

•  Focal nature.

•  Postural.

•  Phonatory (vocalizations or arrest of speech).

•  Eye or truncal deviations.

c.  Somatosensory symptoms.

•  Visual.

•  Auditory.

•  Olfactory.

•  Gustatory.

•  Vertiginous.

d.  Autonomic symptoms.

•  Epigastric sensations.

•  Pallor.

•  Sweating.

•  Flushing.

•  Papillary dilation.

4.  Complex partial.

a.  Impairment of consciousness.

b.  Can start as simple and evolve to loss of consciousness.

c.  May also progress to generalized seizure (partial seizure that secondarily generalizes).

E.  Physical findings.

1.  Generally none on office exam, unless cause of seizure leaves or is cause of a neurological deficit.

F.  Diagnostic tests.

1.  As with generalized seizures, but head MRI warranted.

G.  Differential diagnosis.

H.  Treatment.

1.  Anticonvulsant medications.

a.  Oxcarbazepine (Trileptal), or broad-spectrum anticonvulsant medication.

2.  Surgical intervention if intractable to medications.

3.  Vagal nerve stimulator or ketogenic diet.

I.  Follow up.

1.  As with generalized seizures.

J.  Complications.

1.  As with generalized seizures.

K.  Education.

1.  As with generalized seizures.

XIII.  COMMON ANTICONVULSANT MEDICATIONS FOR CHILDREN

A.  Divalproex (Depakote): Start 10-20 mg/kg/day given bid, liquid tid; maintenance dose 30-60 mg/kg/day.  Monitor CBC with platelets and liver enzymes every 6 months for liver failure, thrombocytopenia.

B.  Levetiracetam (Keppra): Start 10-20 mg/kg/day bid; maintenance dose 30-60 mg/kg/day.

C.  Lamotrigine (Lamictal): Titrate slowly over 8-12 weeks to starting dose.  Risk for Stevens-Johnson syndrome.  Maintenance dose 5-15 mg/kg/day bid; lower dose when on enzyme inducer anticonvulsant.

D.  Topiramate (Topamax): Start 1 mg/kg/day bid; maintenance 3-9 mg/kg/day.  Monitor bicarb for metabolic acidosis.

E.  Oxcarbazepine (Trileptal): Start 10 mg/kg/day bid; maintenance 30-60 mg/ kg/day.

F.  Ethosuximide (Zarontin): Start 10-15 mg/kg/day bid; maintenance dose 15-40 mg/kg/day.  Monitor CBC for leucopenia, aplastic anemia.

G.  Zonisamide (Zonegran): Start 1-2 mg/kg/day daily or bid; maintenance dose 5-8 mg/kg/day.

XIV.  GLOBAL DEVELOPMENTAL DELAY

A.  Subset of developmental disabilities defined as significant delay in two or more of the following developmental domains: gross/fine motor, speech/language, cognition, social/personal, and activities of daily living.