Page 240 - ILAE_Lectures_2015

Chapter 23

Investigation of seizures in infants

RICHARD E. APPLETON1 and AILSA McLELLAN2

1The Roald Dahl EEG Unit, Paediatric Neurosciences Foundation, Alder Hey Children’s
NHS Foundation Trust, Liverpool, and 2Department of Paediatric Neurosciences, Royal
Hospital for Sick Children, Edinburgh

The investigation of seizures in infancy (i.e. within the first year of life) begins with
establishing whether the seizures are epileptic or non-epileptic in origin. The ‘broad’
differential diagnosis of possible seizures and ‘epilepsy’ is multiple and is particularly
difficult under the age of 12 months and includes:

 Gastro-oesophageal reflux (Sandifer’s syndrome)
 Pallid syncopal attacks (reflex anoxic seizures)
 Cyanotic breath-holding attacks
 Cardiac arrhythmias
 Münchausen syndrome by proxy (passive or active  both representing a form of child

abuse)
 Shuddering spells and jitteriness
 Hyperekplexia
 Benign neonatal sleep myoclonus
 Benign myoclonus of infancy
 Tonic reflex activity and involuntary movements (seen in children with neurological

impairment including cerebral palsy or hydrocephalus).

Once a non-epileptic disorder has been excluded or the episodes are considered to be
obviously epileptic, then the following conditions/investigations should be considered on a
chronological basis.

Perinatal (first week of life) and neonatal (first month of life) seizures

The newborn period is the time of life with the highest risk of seizures1-3. This is because of
the relative lack, and immature development of inhibitory neurotransmitters and their
pathways. The immature and developing brain is susceptible to a large number of both
cerebral and systemic insults including:

 Asphyxia (hypoxic-ischaemic encephalopathy)  the most common and also most serious
cause of neonatal seizures – particularly in term infants

 Intra- and periventricular haemorrhage – particularly in pre-term infants
 Metabolic dysfunction (e.g. hypoglycaemia, hypocalcaemia and hyponatraemia)
 Sepsis (most commonly septicaemia or meningitis but also congenital infections,

particularly cytomegalovirus, herpes simplex and HIV-AIDS encephalopathy)
 Cerebral malformation
 Trauma.