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Convulsions in the child: the clinical protocol

Autor: Svetlana Hadjiu Mariana Sprincean Ludmila Feghiu Nadejda Lupușor Corina Grîu Ludmila Cuzneț Cornelia Călcîi Ninel Revenco
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Relevance of the study: Seizures are some of the most common pediatric problems, requiring the patient to be addressed to medical emergency services, and often intensive treatment. During a seizure the bioelectric activity of the brain is disturbed, developing a transient process determined by an abnormal, excessive or synchronous electrical activity, which can lead to changes in consciousness, behavior and/or abnormal movements, usually with sudden onset and end, of short duration, from seconds to minutes, which are detected using electroencephalography, i. e., EEG. Convulsions frighten parents and caregivers; however, most can be controlled with antiepileptic drugs. Th e recognition of epileptic seizures and early therapeutic intervention is essential for the prevention of complications. Scope of the study consists in presenting the National clinical protocol on the convulsions in the child, developed on the basis of international guidelines and assessment of the type of seizures, in accordance with the modern classifi cation of these nosological entities. Methodology of the study: Th e study was based on review of literature, protocols and inernational guidelines. A retrospective analysis medical records of 211 children’s aged from 28 days to 5 years, suspected for epileptic seizures, was carried out to determine the type of the seizure, conform to classifi cation of epileptic seizures, ILAE 2017. Additional examinations are neurological tests, electroencephalographic investigation, i. e., EEG, cerebral imaging, and genetic analysis. Were used methods of statistical processing, i. e., t-criterion Student and confi dence interval evaluation 95CI. Results: Th e results of the study allowed to identify the type of seizure. Th e focal seizures – 120 cases (56,9%; 95CI 53,49-60,31) prevailed over generalized seizures – 56 cases 26,5%; 95CI 23,46-29,54). Also, were determined seizures with unknown type – 24 cases 11,4%; 95CI 9,21-13,59) and unclassifi able seizures – 11 cases (5,2; 95CI 3,67-6,73). Among the seizures prevailed the tonic-clonic seizures – 72 (34,1%; 95CI 30,84-37,36), followed with the tonic seizures – 29 (13,7%; 95CI 11,33-16,07), myoclonic seizures – 17 (8,1%; 95CI 6,23-9,97), epileptic spasms – 10 (4,7%; 95CI 3,24-6,16), clonic seizures – 7 (3,3%; 95CI 2,07-4,53), etc., in descending order, most of the phenomena were encountered. It is not ruled out that in some cases the focal or generalized onset of the crisis was missed, for which reason the unknown or unclassifi able type was confi rmed. Th e results of the EEG changes characterized the type of crisis, but in some cases the type of seizures remained unknown. Imaging and genetic examinations have facilitated confi rmation of some causes of epileptic seizures, especially with structural changes (58 cases, 27,5%; 95CI 24,43-30,57). Genetic pathologies were found only in 5 cases (2,4%; 95CI 1,36-3,44). However, part of the causes of seizures remained unknown (15,6%; 95CI 13,1-,18,1). Seizures were addressed from a therapeutic point of view based on the clinical protocol developed and the present therapeutic algorithm. Conclusion: Th e approach of a child with seizures is based on 6 criteria: Recognizing the epileptic nature of a seizure; Correct therapeutic guidance of the patient during the seizure; Identifi cation of the causes of the seizure; Adherence to the therapeutic principles with anticonvulsant pharmaceuticals; Surveillance of the patient after the seizure; Ensuring of psychological support to the child and family. Th e classifi cation developed for the recognition and diff erentiation of seizures is useful and covers most of the available variants. Further examinations using EEG and cerebral MRI help to identify the type of seizure. Th e recognition of epileptic seizures and early therapeutic approach is essential for the prevention of complications. Timely relief helps to improve the patient’s prognosis. Keywords: convulsions, epileptic, electroencephalography, management, treatment.

Epileptic seizures are the most common neurological manifestations encountered in the child. From 4% to 10% of children experience at least one convulsive crisis during the first 16 years of life [1]. The prevalence of epilepsy among the pediatric population is 4-6 cases/1000 children [2]. The highest incidence is encountered in children under 3 years of age [3], mostly between age 1 and 12 months – 145.8 to 100000 population [4]. Convulsion is a general term that is often used to describe uncontrolled muscle contractions, however, the epileptic seizure refers to an electrical disturbance of the brain. In general, convulsion occurs when the muscles of a person are contracted uncontrolled with duration from seconds to minutes, with the involvement of the whole body, or a certain part of the body [5]. There are several conditions that can cause seizures, including fever, cranio-cerebral trauma, central nervous system (CNS) infections, strokes, epilepsy, etc. Convulsions appear due to bioelectrical disorders of the brain, which determines the occurrence of a transient phenomenon, determined by an abnormal, excessive or synchronous electrical activity, which may lead to changes in consciousness, behavior and/ or abnormal movements, usually with sudden onset and end, of short duration, from seconds to minutes, which are detected using electroencephalogram, i. e., EEG [6]. There are various types of seizures, each with different symptoms. A broad classification of epileptic seizures is given by the International League Against Epilepsy (ILAE), 2017 [7]. Progress in neurobiology and neurogenetics has altered the understanding of epileptic seizures. However, the high frequency of epileptic seizures in children often makes the diagnosis inconclusive and undefined. Errors are made in the recognition of crises, and therefore, in the treatment of the patient with seizures, including too low dose for the patient, too high interval between doses, wrong choice of the drug, wrong choice of route of administration. The recognition of epileptic seizures and early therapeutic approach is essential for the prevention of complications  [8]. In the present work we will try to analyze the information on the classification and diagnosis of various types of convulsions in children, and that will provide the methodological support for specialists in the field.
Is the presentation of the National clinical protocol of management of seizures in the child, developed on the basis of international guidelines and assessment of the type of seizures, in accordance with the modern classification of these nosological entities. Carrying out a study of a group of patients to specify the different type of seizures.
The study based on review literature, protocols and international guidelines. A retrospective analysis of 211 medical records of children aged from 28 days to 5 years, from 2014 to 2018, with seizures, to assess the type of seizure according with the classification of the type of seizure, epilepsy and epileptic syndromes, ILAE 2017. Supplemental examinations were neurological tests, electroencephalographic investigation, i. e., EEG, cerebral imaging by MRI or CT, and genetic analysis. Statistical processing were using t-criteria Student test and confidence interval coefficient 95CI. The children enrolled in study were under supervision of pediatric neurologist during 1 – 4 years ± 11 months, at various medical institutions in Republic of Moldova (RM).

All the patients were divided dependent the type of seizure (Table I). Clinical presentation and EEG results facilitate the appreciation of brain bioelectric changes, which characterized the type of seizure. The focal seizures prevailed – 120 cases ((56,9%; 95CI 53,49-60,31), compared to generalized seizures – 56 cases (26,5%; 95CI 23,46-29,54). Also, seizures of unknown type were detected – 24 cases (11,4%; 95CI 9,21-13,59) as well as unclassified type – 11 cases (5,2; 95CI 3,676,73), (tab. 1). Among the seizures prevailed the tonic-clonic seizures – 72 cases (34,1%; 95CI 30,8437,36), followed by the tonic type seizures – 29 cases (13,7%; 95CI 11,33-16,07), myoclonic seizures – 17 cases (8,1%; 95CI 6,23-9,97), epileptic spasms – 10 cases (4,7%; 95CI 3,24-6,16), clonic seizures – 7 cases (3,3%; 95CI 2,07-4,53), etc., in the descending order, most of the seizures were determined. It is not ruled out that in some cases the focal or generalized onset of the crisis was missed, for which reason the unknown or unclassified type was confirmed. The EEG changes were common to the type of seizure, but in some cases it remained unidentified. Imaging and genetic examinations facilitated the confirmation of some causes of epileptic seizures, preferable with structural changes, i. e., 58 cases, 27,5%; 95CI 24,4330,57. Genetic pathologies were found only in 5 cases (2,4%; 95CI 1,36-3,44). However, the type of some seizures remained unknown (15,6%; 95CI 13,1-,18,1) (Table II). Seizures were addressed from a therapeutic point of view based on the clinical protocol developed and the present therapeutic algorithm (Fig. 1).
Initially, the International League Against Epilepsy (ILAE) defined the seizure as “a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain”. The above definition has been used since the time of Hughlings Jackson, but, according to scientists’ opinions, above definition not taken into account further progress in the field of neuroscience and epileptology in particular [15].

It is correct that the EEG recording would serve as support for confirming the type of the seizure, its classification and localization, as well as can be used for decisions on initiating and cancelling anti-epileptic drug therapy [10, 11]. Thus, the definition of convulsions is as follows: The seizure crisis is a transient event characterized by clinical signs and/or symptom, caused by paroxysmal modification of neurological function due to excessive discharge and hypersynchronous activity of a group of neurons in the brain, which occurs with or without loss of consciousness, being detected using electroencephalogram (EEG) [7, 12, 13, 14]. There are unprovoked seizures, i. e., occurs in the absence of a potentially harmful factor or going beyond the time interval established for the occurrence of acute symptomatic seizures, and provoked seizures, which are influenced by provoking factors. The convulsive seizures, which are a common symptom of epilepsy, are one of the most common and disabling neurological disorders are unprovoked. However, convulsive seizures may also be associated with other conditions caused by seizures itself including the following: acute CNS pathologies, i. e., stroke, trauma, infections, arterial and venous malformations, and hemorrhages, surgical interventions which are were undertaken 7 days before the seizure, systemic pathologies including toxic and metabolic conditions, i. e., hypoglycemia, decreasing the level of calcium, sodium, renal insufficiency, acute hepatitis etc., administering of toxic substances, narcotics, alcohol, and other pharmaceutics, and withdrawal convulsions, etc. It is important to recognize the true convulsive seizure and pathological conditions which are causes of its development, in order to understand the integrity of the physiopathological mechanisms, and to develop the basis for the treatment of epileptic seizures and epilepsies. The analysis of the clinical aspects of seizure was carried out by a group of experts from the ILAE, which subsequently, in 2017, proposed a new classification [7]. Every time where we deal with the patient with seizures it is necessary firstly to define whether this is a convulsive seizure. Then, after we have given help to the patient, it is necessary to determine the cause of the seizure. Every time there is a case of unknown cause, it is necessary to take into account all the methods indicated for the diagnosis. Among them it should be noted the description of the seizure, the data of neurological and somatic examination, the history of the disease, if it is recorded, e. g., a history of epilepsy or febrile seizures, diagnostic tests, such as EEG, neuroimaging, and genetic studies, if they are indicated [16]. Observation, clinical examination, history of seizure and diagnostic tests help specialists in the field to differentiate epilepsy from numerous clinical conditions that mimic a convulsive state, e. g., psychogenic seizure [7, 14, 16]. Recurrent nonprovoked seizures are common to epilepsy, which is due to numerous causes associated with underlying brain damage [16].
A secondary condition of short duration, caused by a reversible cause such as fever, hypoglycemia, etc., can cause the provoked seizure, which does not belongs within the definition of epilepsy. Approximately 15% of children under 15 years of age suffer from various seizures, which are the following: 10% – non-epileptic paroxysmal disorders, 3% to 4% – febrile seizures; 1% to 1.5% – epileptic seizures. The most recent classification of epileptic seizures, epileptics and epileptic syndromes was published in 2017. Seizures are divided into four categories, namely, focal (formerly called partial), generalized, unknown and unclassified. Thus, focal seizures originated from a neuronal network limited to a hemisphere that can be discreetly localized or spread locally, while generalized seizures start at a certain point in the brain and spread rapidly in bilateral distributed networks. Similarly, the seizure can develop focally and subsequently generalize, becoming the focal bilateral. Seizures can come from the cortex or subcortical structures.
To meet the needs of various physicians and researchers, were created as basic (Table I) as well as extended (Table II) versions of seizures classification. The basic version of seizures classification is a short form (Table III) of the extended classification and is intended for pediatricians, non-neurologists, general neurologists, general practitioners, nurses and medical assistants. The extended variant (Table IV) is more detailed and can be used more by epileptologists/ neurophysiologists and researchers. Approach to a child with an acute convulsive seizure is very important, with particular importance of clinical assessment based on history and detailed examination of organs and systems, as well as justified choice of investigations and steps of following guidance. In addition, it is necessary to recognize common non-epileptic events that mimic the epileptic seizure and can be erroneously interpreted as epilepsy. Seizures have the following characteristics: Seizures manifests as severe, involuntary and jerky contractions of muscles, often accompanied by loss of consciousness; Recurrent seizures are determined by a form of epilepsy; Seizures may, in certain circumstances, take place on the healthy brain; Seizures become chronic and repetitive, in circumstances which are determine development of a pathology, i. e., errors in metabolism, trauma, infections, strokes, CNS developmental abnormalities etc. [7]. The focal seizure (FS) is a paroxysmal neural discharge which originating from neural networks within the hemisphere, the discharge is limited to a particular sector in the cortical structures, called epileptic focus. FS may debut with normal, disturbed
or absent consciousness and bilateral tonic-clonic seizures.

The clinical presentation of FS depends on the localization of the epileptic focus, i. e., temporal, parietal, frontal, and occipital, and the surface of the cortex involved. For example, a focal seizure in the occipital lobe may manifest with visual phenomena, the seizure originating from the precentral gyrus with motor clonic or tonic manifestations, and if the seizures originates from postcentral cyrus the manifestations can be sensory, i. e., paraesthesia [16]. FS can be associated with a variety of symptoms, signs and behaviors, including impaired awareness and responsiveness, and withdrawal. The level of consciousness is important for manifesting of any type of focal seizures. If consciousness is impaired during a FS, the seizure is classified as a bilateral focal. Seizures occurring with focus in the temporal lobe are often preceded by auras seconds or minutes before the event. The EEG manifestations of in these cases are unilateral or focal. FS can, however, become generalized in one or both hemispheres, resembling bilateral seizure [7, 8]. Generalized seizures (GS) originating from a focus and are rapidly spreading bilaterally, may include cortical and subcortical structures, but do not necessarily involve the entire cortex. In the table above (Table IV) are presented GS variants, often these are determined by axial contractions of the limbs, can be generalized tonicclonic seizures, i. e., symmetrical bilateral movements of all limbs, with impaired consciousness; myoclonic, i. e., involuntary contractions in one or more muscles, sudden and short-lasting (“lightning-fast”), which are not associated with any obvious disturbance of consciousness; atonic seizures involve the loss of muscle tone, often leading to the drop or fall of the head. GS that starts without contractions are called non-motor seizures [7, 8, 16], including absences, i. e., lack of reaction to external verbal stimuli [16]. Epileptic spasms are manifested by flexion or sudden extension of the limbs, for a few seconds, appear in the series and at any age, in the first year of life are typical for West syndrome [16]. In newborn seizures have some peculiarities, namely, they are limited or atypical, i. e., aversive opercular, apnea; paroxysmal nistagmus, swimming or pedaling movements, and vasomotor phenomena; tonics with limb extension, mimics seizures in decerebration or decortication; the most common types of seizures encountered in the fullterm newborns are clonic multifocal, which are characterized by rhythmic clonuses migrating from one limb to another and focal repetitive and localized in a single limb; there can also be massive myoclonic seizures with sudden movements of high amplitude, contracting of the axial musculature, and lead to the head flexion, the abduction of the arms, the extension of the lower limbs, etc. The vast majority of seizures are symtomatic and appear as a reaction of the brain to an acute lesion, are of short duration, disappearing spontaneously or under the influence of specific etiological treatment; although it may be of epileptic
origin, being generated by hypersyncronic discharges of a neural population, their occurrence in relation to CNS disorder makes them not considered epileptic; there are also epileptic seizures occurring as a result of a chronic CNS disorder with a neonatal onset which can be extremely resistant to specific therapy. Epileptic seizures in the infant are polymorphic. It is currently classified as focal and generalized seizures, with or without loss of consciousness. Focal seizures are often manifesting with an association of motor signs, i. e., clonuses of the eyelids, labial clonuses or hypertonia, involvement of a limb or half of the body, eyes clonuses, conjugated deviation of the head and eyes, automatisms, i. e., gazing and chewing, autonomic seizures, i. e., mydriasis, cyanosis, bradycardia or tachycardia, hyperpnea or apnea [7, 8]. Anyone in human beings can, at some point, develop an epileptic seizure without epilepsy. So, cranio-cerebral trauma, an overload of fluids, a solar radiation, an infection, a meningoencephalitis, an intoxication etc. all can precipitate an epileptic seizure. The chance for a provoked epileptic seizure is very high. The diagnosis of epilepsy requires minimum two individual unprovoked seizure episodes, and a risk of recurrence > 60%, as well as the diagnosis of epileptic syndrome. Some of the most frequent and frightening for the parents convulsive seizures are seizures caused by fever, i. e., febrile seizures, events associated with a fever in the absence of an intracranial infection, hypoglycemia or an acute electrolyte disorder, occurring in children aged 6 months to 5 years, associated with febrile episode > 38°C or 38,5°C rectally, which divided to simple and complex febrile seizures (Table V) [17, 18]. Febrile seizures (FS) are usually generalized tonicoclonic or tonic, although they can be of any type. The EEG exam is not useful in evaluating a child with FS, although some experts suggest that the EEG may be a predictor of febrile or afebrile relapse. It is important to identify the cause of febrile seizures, then, it is called for the need for a lumbar puncture to exclude an intracranial infection. Imaging examination is used only in case of suspected intracerebral process. According to several data, the EEG has a questionable value after a FS, so the routine EEG is not required [17]. If was decided to make an EEG the procedure must be undertaken at least 48 hours after the event, to avoid non-specific errors. Furthermore, early EEG abnormalities after a first complex FS would be unlikely to identify patients at risk of epilepsy [18, 19]. Prolonged seizures may cause the „Status epilepticus”. Status epilepticus (SE) is diagnosed if the duration of seizures exceeding 5 minutes and more. For practical reasons, in particular with regard to clinical management and administration of antiepileptic drugs (AE), it is considered that there are some types of SE: 1. Generalized convulsive status epilepticus (GCSE) is a continuous critical activity, i. e., convulsions, clinical and/or electrical, lasting continuously ≥ 5 minutes, or two or more seizures episodes between which consciousness is not fully recovered, i. e., recurrent critical activity without restoring between seizures. 2. Non-convulsive status epilepticus (NCSE), prolonged electroencephalographic epileptic activity, resulting in non-convulsive clinical symptoms and/or behavioral changes, changes of basic mental processes associated with continuous epileptic-like discharges on the EEG records. 3. Refractory status epilepticus (RSE), condition in which the patient does not respond to standard treatment such as first line benzodiazepines followed by another AE [7, 9, 12, 14]. Causes of SE are varied, including fever, toxic or metabolic factors, anoxia, CNS infections, tumors, craniocerebral trauma, vascular and degenerative diseases, modification of medication, etc. [9, 10, 12]. “Status epilepticus” can lead to irreversible neuronal damage, resulting in severe consequences. The longer the duration of the seizures, the more difficult it is to control it. Clinical characteristics of SE [9] are the following: GCSE is characterized by convulsive seizures associated with rhythmic movements of the limbs, i. e., tonic-clonic, tonic or clonic, altered mental status, i. e., coma, lethargy, or confusion; NCSE characterized by the presence of critical activity showed on EEG but without associated
clinical manifestations; RSE, where patients do not respond to standard treatment of the SE, or who continue to manifest clinical or electrical signs of seizures after receiving appropriate doses of antiepileptic medication. EEG recording can help to differentiate GCSE and NCSE [9, 12, 13, 14]. Important peculiarities in children [9]:

Acute symptomatic SE is more common; Prolonged febrile convulsions is the most common cause of the SE. On typology, convulsive seizures can be manifested by various clinical aspects, which must be recognized by parents and specialists. Using a detailed history, clinical characteristics, seizures classification, EEG findings and additional information, any physician may distinguish the type of seizures, and may further formulate the patient’s assessment plan and appropriate treatment [7, 14]. The frequent question is when to hospitalize a child with convulsive seizures? The answer is: the child with manifestations of simple FS should not be hospitalized, if it is in a good clinical condition and if the source of infection is clear. Preferable to follow the child six hours after an episode of simple FS. In most cases, these manifestations are shortterm and end spontaneously, without requiring longterm treatment with antiepileptic drugs [17, 19]. If the convulsions are long-term, i. e., more than 5 minutes and the child’s consciousness is confused, antiepileptic drugs are administered. AE are indicated if convulsions have duration of more than 5 minutes, if febrile SE is confirmed and in a case of recurrent convulsions [17, 20, 21]. In evaluating a child with FS it is important to recognize the “milestones” or alarm symptoms, which are determined the need for additional therapeutic measures. These are the following: prolonged convulsive seizures; the presence of complex FS; the presence of residual neurological signs, e. g., Todd’s paresis; a serious infection, i. e., positive signs of meningitis, Kernig or Brudzinski and/or neck stiffness, is suspected; changes in consciousness have occurred for more than one hour after seizures has ceased; the source of infection is not determined; the presence of skin rashes in the child; bulging anterior fontanelle; persistent tachycardia after normalizing body temperature; signs of moderate to severe respiratory distress (tachypnea, obstruction, low oxygen saturation < 92% in the air) and chest wall retractions; the child’s age is less than 18 months; there is a risk of reoccurrence of seizures; parents or caregivers are unable to provide adequate monitoring shortly after seizure [17]. If the child presents a convulsive seizures caused by some factors, the causes are identified and treated, the treatment of seizures is prescribed in accordance with their specificity. If the seizures are primary unprovoked, it is need to carry out a detailed examination of the child and if the cause is not established, it should be clarified later. Hospitalization criteria: infant or small age of the patient, SE of any type, convulsive seizures associated with other major medical or surgical emergencies [10, 11]. Clinical signs of alarm of convulsive seizures/ threat for life: risk of development of SE, anoxia, aspiration or trauma secondary to loss of consciousness, respiratory arrest secondary to AE administering, cardiovascular disease, acute cerebral edema, neural lesions and hypoxic encephalopathy [9, 12]. Paraclinic examinations: Complete blood count (CBC), urinalysis (UA), blood biochemical analysis, e. g., basic metabolic panel (BMP), blood glucose, ionogram, ECG monitoring, EEG, CT and/or cerebral MRI (if applicable), and lumbar puncture (if applicable) [7, 9, 12, 114]. EEG should be performed: in children with complex FS; at the onset; in the combination of febrile and afebrile seizures; in prolonged postictal neurological deficiency; in previously recorded neurological abnormalities. Dealing with acute convulsive seizures, it is important to follow the recommendations of the clinical protocols, which highlight of first-aid measures: during the seizure, do not move the patient unless they are in a dangerous position; remove objects that may cause injury; do not try to immobilize the patient but protect him from potential hazards, ensuring head protection; do not put anything in the mouth of the patient, if there is no danger of swallowing his tongue; after the seizures, if the patient is unconscious, give his head back to release the airway and check for respiration; place the patient on one side in the lateral position to ensure normal breathing and supervise the patient until fully recovery; addressing to the emergency service. It is important to indicate whether the seizures lasted more than 5 min or if they were repeated, whether the unconscious is maintained, whether the convulsions been recurrent. Therapeutic approach to convulsive seizures [9, 10, 11, 12, 13, 14]: 1. Observation and visual monitoring, ECG and oximetry, re-evaluation and frequent (every 5 min) recording of vital signs and neurological status (Figure 1). 2. Adherence to the principles of treatment with antiepileptic drugs (AE): – rapid administering of AE; – using the correct dose of AE; – compliance of correct administering; – avoidance of small and frequent doses or insufficient individual doses, which prolong the period of time in which the optimum therapeutic level can be achieved; – monitoring of the patient’s condition after each dose of AE every 5 min while the crisis continues, and every 15 min after the crisis ends, until the level of consciousness returns to normal; – continuous re-assessment and monitoring of vital signs and/or symptoms and neurological status within the first 6 – 12 hours after the seizure onset in order to prevent recurrences (exception: simple FS); – timely decision to move to the first line therapy. 3. The most common errors in the treatment of the patient with convulsions: – insufficient dosing of medications, – too long time interval between the doses, – erroneous choice of the drug, – erroneous choice of the route of administering. Pharmaceutical therapy of FS is carried out in accordance with the recommendations (Figure 1, Tables VI, VII) [11, 14, 17, 18, 19, 20, 21, 22, 23]. Criteria for discharging: Seizure ceasing and control, stabilized health parameters. Prognosis: Risk of recurrence of convulsive seizures; cancelling of antiepileptic treatment after several convulsive seizures; increasing frequency of seizures; resistance to treatment with antiepileptic drugs; structural, metabolic or genetic etiology; impairment of cognitive, behavioral and social skills; predisposing to a complicated prognosis [7, 16]. Recommendations for parents: Child supervision by neuropediatrics, administration of Diazepam rectal tube in case of recurrence of seizures, addressing to UPU service [11, 12, 14]. CONCLUSIONS Approach to the children with convulsive seizures is based on 6 criteria: recognizing the seizures as a convulsive; Correct guidance of the patient during the seizure; Identification of the causes of seizures; Adherence to the principles of treatment with antiepileptic drugs; Follow up of the patient after the seizure; The provision of psychological assistance to the child and family. The classification developed for the recognition and differentiation of convulsive seizures is useful and covers most of the seizures variants. Further examinations using EEG and cerebral MRI help to identify the type of seizures. The recognition of epileptic seizures and early therapeutic measures is essential for the prevention of complications. Timely medical assistance helps to improve the patient’s prognosis. 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