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Cerebral Palsy - Increased Seizures

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  • See also

    Afebrile seizures
    Cerebral palsy
    Cerebral palsy: chest infection

    Cerebral palsy: pain and irritability

    Key Points

    1. Assessment of conscious state and responsiveness may be difficult. Pay attention to parental concern
    2. Take a medication history focusing on anti-epileptic drugs (AED), benzodiazepines and baclofen
    3. Manage acute seizure as afebrile seizures
    4. Ensure emergency seizure management plan is updated

    Background

    Seizure disorders occur in up to half of children with cerebral palsy

    • They are associated with worse motor function and may be difficult to control
    • Both generalised and focal seizures are seen in children with cerebral palsy

    Cessation of intrathecal baclofen can cause withdrawal, presenting as dystonia and dyskinesia resembling status epilepticus

    Assessment

    Assessment and management should occur concurrently if the child is actively seizing. See afebrile seizures

    Seizures must be considered as a differential diagnosis in the following settings:

    • change in usual behaviour
    • deterioration in motor function
    • sudden falls
    • cognitive decline
    • sleep disturbance

    Precipitants of seizures

    • Intercurrent illness eg febrile illness, chest infection, UTI
    • Changes in medication, specifically AED or missed doses of AED
      • breakthrough seizures can occur with missing any of the AED 
      • carbamazepine and oxcarbazepine result in more severe seizures upon abrupt withdrawal
    • CNS infection
    • VP shunt malfunction

    History

    • History of previous seizures, seizure phenotypes, emergency management plan (if in place) and AED 
    • Benzodiazepine use (consider cumulative dosing and tolerance)
    • Duration of seizure (including pre-hospital period)
    • Focal features (limb or eye movement)
    • Vomiting, diarrhoea or feed intolerance causing reduced absorption of AED
    • Exposure to medications that reduce seizure threshold eg tramadol, tricyclic antidepressant, antihistamine
    • Presence of VP shunt
    • Presence of intrathecal baclofen pump

    Examination

    • Conscious state and responsiveness  
    • Consider subtle signs of ongoing seizure activity eg eye deviation
    • VP shunt if present

    Management

    • See afebrile seizures for management of acute seizure
      • Optimise head position, consider left lateral position if risk of aspiration
      • Consider simple airway manoeuvres (head-tilt chin-lift or jaw thrust)
      • Consider oro/nasopharyngeal airway for upper airway obstruction
      • Suction secretions/blood/vomit
    • Treat intercurrent illness as appropriate
    • Assessment of conscious state and responsiveness may be difficult
      • Failure of improvement of conscious state post seizure or worsening conscious state requires re-evaluation and consideration of investigations including lumbar puncture (LP) and neuroimaging. Seek senior advice
    • Consider the possibility of non-convulsive status particularly in those with seizure disorders with multiple seizure types. This may require EEG confirmation. Seek senior advice
    • Adjustments to maintenance AED should be discussed with the consultant responsible
    • Ensure discharge plan includes an updated emergency seizure management plan

    Consider consultation with local paediatric team when

    • Prolonged seizures, incomplete recovery or status epilepticus
    • Increasing frequency of seizures in a child with a known seizure disorder

    Consider transfer when

    • Status epilepticus
    • Children anticipated to required ICU level care (cardiorespiratory compromise)

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    Consider discharge when

    • Child is back to usual level of consciousness and function, and able to tolerate AED (if taking)
    • An updated emergency seizure management plan is provided
    • Follow-up in place 

     

    Last updated July 2023

  • Reference List

    1. Gabis, LV et al. Assessment of Abilities and Comorbidities in Children with Cerebral Palsy. Journal of Child Neurology. 2015. 30(12) p 1640-1645.
    2. Karim, T et al. Improving epilepsy control among children with cerebral palsy in rural Bangladesh: a prospective cohort-based study. BMJ Open. 2022. 12e052578. doi:10.1136/bmjopen-2021-052578
    3. Latzer, IT et al. Prediction of Drug-Resistant Epilepsy in Children with Cerebral Palsy. Journal of Child Neurology. 2020. 35(3), p187-194.
    4. NICE guideline [NG62]. Cerebral Palsy in under 25s: assessment and management. Retrieved from https://www.nice.org.uk/guidance/ng62 (viewed 07 Sept 2022).
    5. NICE guideline [NG217]. Epilepsies in children, young people and adults. 2022. Retrieved from https://www.nice.org.uk/guidance/ng217 (viewed 07 Sept 2022).
    6. Singhi, P et al. Epilepsy in Children with Cerebral Palsy. Journal of Child Neurology. 2003. 18(3), p175-179.
    7. Tsubouchi, Y et al. Long-term prognosis of epilepsy in patients with cerebral palsy. Developmental Medicine & Child Neurology. 2019. 61, p1067-1073. doi: 10.1111/dmcn.14188.