Epilepsy in Children

Background

• The International League Against Epilepsy (ILAE) defines epilepsy as a disease of the brain defined by the following:
  • 2 or more unprovoked or reflex seizures occurring > 24 hours apart
  • single unprovoked (or reflex) seizure and high-risk of recurrence over the next 10 years
  • diagnosis of an epilepsy syndrome
• The ILAE classifies seizures as 1 of 3 types (focal, generalized, and unknown) with optional subclassifications based on additional features.
• Some of the risk factors for the development of epilepsy in children may include traumatic brain injury, pregnancy-related factors, and birth-related factors.
• The causes of epilepsy can be divided into several categories by age of onset, genetic, structural, metabolic, and other (idiopathic, autoimmune, distinctive constellations, and infection).
• Epilepsy may resolve in children:
  • with age-dependent epilepsy syndrome who have aged past applicable age range
  • who become seizure free after first prescribed drug
  • who are free of seizure for preceding 10 years and no longer taking seizure medication for ≥ 5 years

Evaluation

• Perform a complete history and thorough physical examination on all children suspected of epilepsy.
• The clinical presentation of epilepsy in children is quite variable and depends on the age of the patient and type of seizure.
• Differentiate true epileptic events (seizures) from nonepileptic events.
• Obtain an interictal electroencephalogram (EEG), with hyperventilation and photic stimulation, after a second epileptic seizure to support an epilepsy diagnosis.
• Consider neuroimaging with brain magnetic resonance imaging (MRI), which is the modality of choice, or computed tomography (CT), to classify the seizure type and/or to identify an underlying etiology.
• In patients with an unclear diagnosis consider blood testing, electrocardiography (ECG), or other diagnostic testing.

Management

• The goals of management for epilepsy in children are seizure control with minimal adverse events, and supporting quality of life; management considers epilepsy syndrome, seizure type, and patient characteristics, including age, sex, and comorbidities if present.
• The treatment of epilepsy in children should be initiated by a specialist.
• Begin treatment with antiseizure medications (ASMs) where the selection is dependent on the diagnosed seizure type or syndrome.
• For ASM medically refractory epilepsy, consider:
  • other medications such as
    • immunomodulators
    • pyridoxine
    • cannabidiol
  • dietary management
  • surgical management
  • vagus nerve stimulation
  • complementary and alternative therapies
• Offer counseling to patients and/or caregivers to emphasize the importance of following the treatment regimen for seizure control.
• Assess the response to treatment at regular intervals.
• Do not routinely monitor lab work unless clinically indicated or recommended by a specialist.
• Consider gradual ASM discontinuation after ≥ 2 years of seizure freedom.