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