Neobook — clinical reference

DESCRIPTION

Central nervous system infections are a common cause of epileptic seizures in children under 13 years of age in South Africa. The most common seizures in children are febrile seizures (See Febrile seizures) but history, examination and investigations must aim at excluding the following conditions:

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Special considerations by age group

Neonates:
Neonatal seizures are usually provoked, most commonly by hypoxic ischaemic encephalopathy (HIE). They rarely lead to a subsequent diagnosis of epilepsy. For management, refer to Seizures, Neonatal.

Infants and children up to 2 years of age:

The most frequent cause of epileptic seizures that present in infancy are febrile seizures (See Febrile seizures).
Infants under 6 months of age cannot manifest generalised tonic-clonic seizures.
Most provoked seizures presenting in this age group appear to be focal, even when a generalised brain pathology is present.
Infants and children under 2 years may not have typical signs of meningitis, i.e. neck stiffness or Kernig sign. Meningitis should be excluded in all children with a fever and seizure.
Infants and children are at risk of metabolic derangement which may be from common triggers (e.g., dehydration) or rare causes (e.g., inborn errors of metabolism).
Neuroimaging is often useful, especially to exclude structural aetiologies (e.g., intracranial bleeds).

Children 2 to 12 years of age:

Older children are often able to present with clearer descriptions of seizure onset, i.e. a focal onset seizure is more likely to be specifically driven by an underlying focal cause (potentially a structural pathology):

Ask about focality – point to the side of movement or change.
Change in behaviour before convulsive seizure becomes evident.
Altered consciousness.
Type of seizure is related to the underlying aetiology.

GENERAL MEASURES

On arrival/ while fitting:

Ensure the environment is safe. Remove all sharp objects and hot liquids.
Place the child in a recovery position to prevent aspiration of secretions or vomitus, on the floor if necessary.
Do not place anything (spoon or spatula, etc.) in the patient's mouth.
Ensure that the airway is not obstructed.

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Adapted from https://www.kidshealth.org.nz/emergencies/emergencies-cpr

LoE:IVb⁶

Administer oxygen via face mask or nasal cannula to maintain SaO₂ ≥ 95%.
Obtain eyewitness account of when the seizure started and associated impaired consciousness: If seizure duration is ≥ 5 minutes, commence urgent medicine treatment for convulsive status epilepticus (refer to table below on medicine management and supportive care of status epilepticus in children < 13 years of age).
Examine for fever; dehydration; meningism; hypoglycaemia; evidence of toxin or poison ingestion; head, neck or other trauma; obvious focal neurology; and other possible causes of the seizure.
Establish vascular (IV or IO) access, if possible. See Intra-osseous infusion in emergencies.
Once threat of falling is no longer present, move to bed (with cot sides are up), if needed.
Monitor vital signs every 15 minutes.
Keep nil per mouth.
Ensure the family/caregiver/escort is attended to. Social worker or auxiliary staff member should obtain all contact details and provide counselling as needed.

MEDICINE TREATMENT

The aim is to control the seizure within 30 minutes of its onset, prevent complications of status epilepticus with supportive care, and identify and correct underlying causes. Follow standard resuscitation protocols, such as the ABCDE approach.

Table 1: MEDICINE MANAGEMENT AND SUPPORTIVE CARE OF STATUS EPILEPTICUS IN CHILDREN < 13 YEARS

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Link in image above: See Rapid sequence intubation.

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Links in image above:

See: Raised intracranial pressure.

See: : Standard paediatric dosing tables.

AFTER THE SEIZURE:

Post-ictal phase

Keep nil per mouth and haemodynamically stable until child has regained consciousness.
Determine the seizure type (focal or generalised) and cause of the seizure. Further investigations are driven by clinical signs and seizure onset, e.g.:
- History of toxin exposure
- Evidence of neuro-infection
- History of trauma
- Focal onset (e.g., a warning experience prior to generalised tonic-clonic movements) and/or focal neurology warrants neuroimaging.
If meningitis cannot be excluded, commence antibiotic therapy within one hour of arrival. Refer to Paediatric Hospital Level STGs and EML, Meningitis, acute bacterial; Meningo-Encephalitis/Encephalitis, acute viral. Also refer to Primary Health Care STGs and EML, Acute meningitis.

Pre-discharge

Consider whether the criteria for a diagnosis of epilepsy are met (see Epilepsy). Initiate appropriate ASM for type of epilepsy and develop an emergency care plan for recurrent seizures.
If not epilepsy, start weaning any ASMs.
Counsel the caregiver on the current state of the child, the reason for the seizure, management given and likely sequelae of the seizure. Offer only as much information as the caregiver can receive at that time.
Set up a follow up appointment to re-evaluate the diagnosis, educational and social needs, and to reinforce educational counselling about the child’s condition.

Active follow-up

Ensure underlying medical conditions are appropriately managed.
Reduce and stop any residual ASMs if not epilepsy.
Assess neurodevelopmental conditions, educational and social needs. Refer as necessary.
If epilepsy is the cause of the seizure, check seizure control and if emergency care plan is understood.

REFERRAL

Refractory status/lack of High Care/ICU beds.

Click here to access the pdf.

Click here to access NEMLC Report.

Standard Treatment Guidelines and Essential Medicines List for South Africa, Paediatric Hospital Level_Updated May 2025

Chapter 13: The Nervous System_13.2 Status Epilepticus_13.2.1 Epileptic Seizures and Status Epilepticus in Children <13 Years of Age