Managing and Treating Seizures in Children

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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 continue this discussion with how a seizure is classified in order to evaluate how to treat seizures in children. 

Types of Seizures  

Seizures are categorized as focal, generalized, status-epilepticus, or unclassified. Focal or partial seizures originate in one area of the brain. It is considered a simple focal seizure if consciousness is not impaired. The symptoms depend on which area of the brain is affected. If consciousness is impaired, it is considered a complex focal seizure. Focal seizures may be preceded by pre-seizure symptoms such as subjective sensations or physical symptoms that warn of an imminent seizure. A complex focal seizure can start out as a simple seizure. It is possible for focal seizures to spread to the other side of the brain and become generalized seizures. Generalized seizures affect both hemispheres of the brain and are not associated with pre-seizure symptoms.  

Consciousness may be impaired briefly as with absence seizures (brief staring spells accompanied by a lapse in consciousness) or for longer periods, as with tonic-clonic (convulsive seizures). Typically, generalized seizures are convulsive, though some (absence seizures and atonic seizures for example, in which a person loses muscle tone) are not (3).  

Other types of generalized seizures are myoclonic which are brief contraction of a muscle or muscle groups, clonic, which is asymmetrical jerking; and tonic, which is a sudden increase in the body’s muscle tone that causes the muscles to contract. Status-epilepticus is a prolonged generalized tonic-clonic seizure or at least two back-to-back seizures without full recovery. Unclassified seizures in children cannot be classified because there is inadequate data (4). The type of seizure the child is having will determine which type of first aid and treatment he or she should receive. In order to implement effective seizure management, it is important for the nurse to be familiar with the seizure classification system. 

Seizure Management: The Nurse’s Role  

Seizure management 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 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 vs. a non-convulsive seizure. For a convulsive seizure: 

• The parent should 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 
• Time 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 
• Time the seizure 
• Don’t grab or hold your 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 safety precautions. One of the biggest risks to a child who has seizures is where they occur: 

• Avoid tub baths 
• Ensure that the bathroom door is not locked 
• Do not swim unless there is constant supervision 
• Wear a helmet when bike riding 
• Do not cook over an open stove 
• Teenagers with uncontrolled seizures should 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 should have the child’s name, date of birth, parent or guardian’s phone number, emergency contact, and treating physician. The seizure action plan will have a place to document the type of seizure, 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. 

Pharmacologic and Nonpharmacologic Management of Seizures in Children 

Finally, the nurse should instruct the family on the treatment prescribed for their child’s seizures. There are pharmacologic and non-pharmacologic treatments. Pharmacologic therapy would consist of medications; there are many medications used to treat seizures, as some are indicated for certain types of seizures. Other considerations would include patient characteristics such as age, sex, ethnicity, and comorbid conditions. Some anti-seizure drugs have adverse effects.  Non-pharmacological treatment consists 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 VNS device is a small stimulator that is surgically implanted under the left clavicle with a lead attached from the device 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 and has been studied mostly in children. 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. 

Case Study  

A 14-month-old developmentally normal boy who presents with generalized tonic-clonic seizures. This is the child’s first seizure episode.

1. How would you initiate management? 
2. What other information would be useful to you as you are starting to intervene? 
3. What education would you provide for the family? 

Conclusion 

In conclusion, a nurse’s role is vital when seizures in children occur. They must empower families with the necessary tools to live with seizures. Seizures can be unpredictable and frightening. Families need and rely on 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 plan, tips for coping, support, and resources available. The nurse has a unique role in equipping families with what they need to survive a seizure. 

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